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SOUTHARD    MEMORIAL    NUMBER 

Volume  IV  No.  I  I 


BULLETIN 


MASSACHUSETTS  DEPARTMENT 
OF  MENTAL  DISEASES 


(PUBLISHED    QUARTERIA'; 


February,  1920 


Columbia  33mbersttj> 
in  tfje  Cttp  of  jBLeto  gorfe 

College  of  ^fjpstctans  anb  burgeons 


Reference  Ht&rarp 


5 


£  £~*jmwmL . 


SOUTHARD    MEMORIAL   NUMBER 

Volume  IV  No.  1 


BULLETIN 

OF  THE 

MASSACHUSETTS  DEPARTMENT 
OF  MENTAL  DISEASES 

(PUBLISHED    QUARTERLY) 


Edited  under  the  Provisions  of  Acts  of  1909,  Chapter  504,  Section  6,  by 

WALTER  E.   FERNALD,   M.D. 
GEORGE  M.  KLINE,   M.D. 


February,  1920 


Publication  of  this  Document 

approved  by  the 
Supervisor  of  Administration. 


CONTENTS. 


Foreword,       .  .         .         .         . 

Resolutions  adopted  by  Department,  .... 

Memorial  Notice  by  Wm.  N.  Bullard,  M.D., 

An  Appreciation  of  Elmer  E.  Southard  by  Richard  C.  Cabot,  M.D. 

Bibliography  arranged  by  years,        .  .  . 


PAGE 

5,6 

7 

8-13 

14-29 

30-199 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/bulletinsouthardOOmass 


SOUTHARD  MEMORIAL  NUMBER. 


FOREWORD. 


Dr.  E.  E.  Southard  was  closely  identified  with  the  Massachu- 
setts State  Hospital  service  from  May,  1906,  to  Feb.  8,  1920, 
nearly  fourteen  years.  His  early  (1902)  friendship  with  Prof. 
A.  M.  Barrett,  then  pathologist  at  the  Danvers  State  Hospital, 
and  his  association  with  him  in  the  department  of  neuropathology 
at  the  Harvard  Medical  School,  made  his  appointment  a  natural 
one  at  Danvers,  when  Dr.  Barrett  was  called  to  Michigan  to  be 
the  director  of  the  Psychopathic  Hospital  at  Ann  Arbor  in  1906. 

From  May,  1906,  to  May,  1909,  Dr.  Southard  was  actively 
engaged  in  conducting  laboratory  work,  always  exhibiting  a 
genial  leadership,  stimulating  others  to  want  to  work,  and  col- 
laborating with  all  in  plans  for  scientific  investigations.  He 
brought  to  the  State  service,  even  at  this  time,  a  perspective 
which  tempered  the  enthusiasms  of  aggressive  staff  workers, 
while  his  outside  interests  kept  him  from  the  excessive  loyalties 
which  narrow  vision.  He  continued  to  be  a  pathologist  to  the 
Danvers  State  Hospital  until  1909,  when  gradually  the  general 
needs  of  the  State  were  recognized  by  Charles  W.  Page,  super- 
intendent of  the  Danvers  State  Hospital,  as  paramount,  and  Dr. 
Southard  was  made  pathologist  to  the  State  Board  of  Insanity.  It 
was  his  duty  to  supervise  the  hospital  laboratories,  to  which  visits 
were  made  to  stimulate  scientific  work,  but  his  mind  was  more 
particularly  occupied  with  plans  for  the  Psychopathic  Hospital 
of  which  he  was  appointed  director  in  June,  1912.  The  same 
year  that  he  was  made  pathologist  of  the  State  Board  of  Insanity, 
in  1909,  he  was  also  made  Bullard  Professor  at  the  Harvard 
Medical  School,  which  title  he  held  to  the  last. 

His  seven  years'  work  in  the  Psychopathic  Hospital  is  well 
known;  what  his  next  decade  of  activities  would  have  produced 
as  the  director  of  the  newly  created  Psychiatric  Institute  can 
only  be  surmised.  No  doubt  he  would  have  continued  to  produce 
new  truths  in  whatever  field;  to  attack  the  most  puzzling  psychi- 


atric   problems;     and    to   inspire   his   pupils    with   a   passion   for 
knowledge. 

The  Department  of  Mental  Diseases  lost  its  most  brilliant 
officer  Feb.  8,  1920,  after  an  eventful  week  of  medical  addresses 
in  New  York  City.  The  publication  committee,  in  token  of 
the  esteem  in  which  he  was  held  by  the  Department  of  Mental 
Diseases,  prints  this  bulletin  in  his  honor. 

GEO.  M.  KLINE. 
WALTER   E.  FERNALD. 


RESOLUTIONS  ADOPTED  BY  THE  DEPARTMENT   OF 
MENTAL   DISEASES. 

Whereas,  The  Commonwealth  has  lost  a  faithful  servant 
through  the  death  of  Dr.  Elmer  Ernest  Southard,  Director  of  the 
Psychiatric  Institute,  on  Feb.  8,  1920,  we,  the  members  of  the 
Department  of  Mental  Diseases,  desire  to  record  our  great 
sorrow  at  his  loss,  and  our  high  appreciation  of  his  valuable 
service  to  the  Department,  to  the  institutions  under  its  super- 
vision, and  to  the  Commonwealth.  Dr.  Southard  entered  the 
service  of  the  State  in  1906,  at  the  Danvers  State  Hospital, 
where  his  work  attracted  attention,  and  he  was  made  pathologist 
to  the  State  Board  of  Insanity  in  1909.  "With  the  opening  of  the 
Psychopathic  Department  of  the  Boston  State  Hospital  in  1912, 
Dr.  Southard  was  chosen  as  its  director,  while  still  acting  as 
pathologist  to  the  Board.  He  continued  at  the  Psychopathic 
Department  until  appointed  as  director  of  the  Massachusetts 
State  Psychiatric  Institute  in  1919,  where  his  work  of  usefulness 
covered  the  entire  State.  His  brilliancy  of  mind,  far-sightedness, 
unlimited  capacity  for  work,  and  kindly  disposition  made  him 
invaluable  to  the  Commonwealth  he  so  ably  served.  His  associ- 
ates will  miss  him. 

Those  interested  in  scientific  research  for  the  mentally  sick 
and  feeble-minded  well  know  how  great  a  debt  of  gratitude  the 
Commonwealth  owes  to  Dr.  Southard. 

As  a  recognition  of  his  service,  the  members  of  the  Depart- 
ment of  Mental  Diseases  desire  and  order  that  this  memorandum 
be  spread  upon  the  records  and  a  copy  thereof  sent  to  Mrs. 
Southard. 


8 


MEMORIAL  NOTICE.1 

By  William  N.  Bullard,  M.D. 

Dr.  Elmer  E.  Southard  was  born  in  Boston  in  1876,  was 
educated  in  the  public  schools,  and  entered  Harvard  College  in 
1893,  graduating  with  the  degree  of  A.B.  in  1897,  and  A.M.  in 
1902. 

As  a  boy  he  seemed  to  have  been  in  no  way  unusual,  except 
that  he  took  many  medals  and  prizes  at  school.  In  college  he 
was  much  interested  in  philosophy,  and  studied  under  both 
James  and  Royce.  This  interest  lasted  him  throughout  life,  and 
as  long  as  Royce  lived  and  taught,  Southard  attended  his  semi- 
naries at  Cambridge.  Once,  indeed,  when  Royce  was  incapaci- 
tated, Southard  took  some  of  his  work  for  a  time. 

His  chief  outside  interest  while  in  college  was  chess.  He 
became  an  expert  amateur  chess  player,  was  chosen  to  represent 
Harvard  in  the  matches  with  Yale,  and  was  a  member  of  the 
Harvard  Chess  Club.  In  later  years,  when  he  was  working 
hard  in  the  medical  school  or  hospital,  he  told  me  that  his 
relaxation  used  to  be  to  go  down  to  New  Haven  in  the  evening 
and  play  chess  all  night.  He  sometimes  played  chess  blind- 
folded. The  very  unusual  powers  thus  shown  undoubtedly 
displayed  themselves  later  in  his  work. 

On  leaving  Harvard  College,  Dr.  Southard  entered  the  Har- 
vard Medical  School,  taking  his  M.D.  degree  in  1901.  He  was 
made  pathological  interne  in  the  Boston  City  Hospital  in  1901, 
and  later  assistant  in  pathology  in  1903.  In  1901-02  he  was 
abroad  for  a  time  at  Frankfort  and  Heidelberg.  In  1904  and 
1905  he  was  assistant  visiting  pathologist  at  the  Boston  City 
Hospital,  and  at  this  time  (1904-05)  became  instructor  in  neuro- 
pathology in  the  Harvard  Medical  School.  From  this  time  on  he 
continued  steadily  in  the  work  of  neuropathology,  his  life  work, 
becoming  assistant  professor  in  1906,  and  in  1909  Bullard  pro- 
fessor of  neuropathology,  which  position  he  held  at  the  time  of 
his  death. 

Dr.  Southard,  in  later  years  especially,  was  a  prolific  writer. 
He  read  many  papers  before  many  medical  societies  and  associa- 
tions, and  he  was  a  member  of  all  the  prominent  national  med- 

1  Published  in  the  Boston  Medical  and  Surgical  Journal,  April  8,  1920. 


9 

ical  societies  in  his  line  and  many  others.  His  first  paper  of 
which  we  have  record,  published  in  1901,  was  "A  Case  of 
Glioma  of  the  Frontal  Lobe,"  a  purely  pathological  account  of  a 
cerebral  condition.  He  wrote  little  in  the  next  two  years,  but  in 
1904,  or  1904-05,  published  six  papers,  all  purely  pathological. 
In  1905  and  in  1905-06  we  find  five  papers  written  either  alone 
or  in  collaboration  with  others,  all,  as  before,  neuropathological 
in  the  narrowest  sense  (pathological).  In  1906  Dr.  Southard 
became  pathologist  at  Dan  vers  State  Hospital,  and  he  held  this 
position  and  that  of  assistant  physician  in  the  same  hospital  from 
1906  to  1909.,  We  have  records  of  four  papers  published  in  1906 
and  two  in  1907,  all  of  the  same  pathological  nature.  The 
"Outline  of  Neuropathology"  was  published  in  1906.  During 
these  years  (1906-09)  Dr.  Southard  was  much  occupied  at 
Danvers,  not  only  in  collating  and  arranging  his  thousand 
autopsies  in  order  to  form  a  basis  for  his  future  work,  but  in 
attending  the  early  morning  clinics  at  the  hospital,  and  in  very 
interesting  investigations  with  Dr.  Gay  into  certain  aspects  of 
anaphylaxis.  This  work  was  specially  valuable  to  Dr.  Southard, 
as  it  was  the  first  opportunity  to  widen  and  broaden  his  field  of 
work.  How  important  this  was  he  early  perceived,  and  he  under- 
stood that  neuropathology,  as  it  should  be  conceived  and  as  it 
was  defined  from  the  terms  of  the  gift  of  endowment  of  the  pro- 
fessorship, was  not  simply  the  study  of  pathological  details, 
however  important  a  part  these  might  play  as  a  foundation  or 
basis  for  other  investigations,  but  comprised  many  wide  and 
far-reaching  issues,  touching  and  forming  links  with  many  allied 
subjects.  Many  of  these  allied  subjects  became,  as  they  were 
more  nearly  approached  and  more  closely  examined,  so  inti- 
mately connected  with  and  concerned  in  the  stricter  neuro- 
pathological investigations  that  they  necessarily  became  a  part, 
and  were  included  in  the  observations  and  researches,  of  the 
more  experienced  neuropathologist.  They  became  an  actual  part 
of  the  subject  of  neuropathology  in  its  widest  and  truest  aspect. 

From  this  time  on  the  scope  of  his  work  grew  ever  wider  and 
wider.  He  also  studied  other  collateral  lines  of  work,  as  when 
he  went  to  England  in  the  summer  of  1907  to  work  with  Sher- 
rington on  physiology. 

In  1907-08  he  published  with  Dr.  Gay  the  article  "On  Serum 
Anaphylaxis  in  Guinea  Pigs,"  which  assumed  much  importance 
at  the  time,  and  he  also  published  at  this  time  four  other  papers, 
all  on  pathological  subjects. 


10 

In  1908  "The  Relative  Specificity  of  Anaphylaxis"  was  pub- 
lished in  collaboration  with  Dr.  Gay,  and  also  four  articles, 
entitled  "Further  Studies  in  Anaphylaxis,"  with  the  same 
author.  In  addition  to  these  there  were  seven  other  papers, 
clinical  or  pathological. 

In  1908-09  there  was  published  in  the  "American  Journal  of  In- 
sanity" an  article  by  Dr.  Southard  and  Dr.  H.  W.  Mitchell,  entitled 
"  Clinical  and  Anatomical  Analysis  of  23  Cases  of  Insanity  arising 
in  the  Sixth  and  Seventh  Decades,  with  Special  Relation  to  the 
Incidence  of  Arterio-Sclerosis  and  Senile  Atrophy  and  to  the 
Distribution  of  Cortical  Pigments."  This  was  one  of  the  first 
contributions  from  the  analysis  of  the  Danvers  cases  which  later 
furnished  the  basis  for  so  many  observations. 

It  is  not  worth  while  to  detail  the  many  papers  or  articles  of 
so  prolific  a  writer  further  than  to  point  out  work  of  special 
interest  from  some  standpoint.  In  1909,  besides  many  other 
papers,  Southard  published  three  on  bacillary  dysentery,  follow- 
ing the  epidemic  thereof  at  Danvers  in  1908. 

In  1910  came  the  paper  on  "Senile  Dementia,"  and  his  work 
on  "Dementia  Prsecox"  was  started. 

The  year  1912  was,  again,  a  very  active  one,  with  articles  on 
the  Psychopathic  Hospital,  of  which  he  had  become  director, 
and  on  "Normal  Looking  Brains"  from  the  Danvers  material. 

In  1914  a  most  suggestive  paper  on  "Lesions  of  the  Optic 
Thalamus"  was  published,  and  one  on  "The  Topographical  Dis- 
tribution of  Certain  Lesions  and  Anomalies  in  Dementia  Prsecox." 

These  last  years  were  more  or  less  fully  occupied  with  his  work 
at  the  Psychopathic  Hospital,  where  he  gave  clinics.  After  the 
details  of  management,  arrangement  and  teaching  at  the  Psycho- 
pathic Hospital  had  been  somewhat  settled,  Dr.  Southard  was  at 
liberty  for  a  short  time  to  give  attention  to  the  great  problems 
of  neuropathology,  and  at  this  time  he  began  to  put  into  appli- 
cation a  principle  which  he  had  long  carefully  thought  out. 
This  was  the  application  of  facts  and  classifications  in  one 
branch  of  knowledge  to  another  apparently  only  distantly  re- 
lated. His  first  attempt  at  this  seems  to  have  been  "On  the 
Application  of  Grammatical  Categories  to  the  Analysis  of 
Delusions."  The  idea  that  the  principles,  categories  and  classi- 
fications used  in  grammar  could  be  applied  with  advantage  in 
the  analysis  of  mental  states  was  an  illuminating  one.  Dr. 
Southard  studied  grammars  of  various  languages  carefully,  and 
sought  to  obtain  the  principles  on  which  the  languages  were  built. 


11 

He  was  also  a  great  student  of  the  dictionary,  —  of  words, 
and  of  the  meanings  and  derivations  of  words.  This  knowledge 
had  a  fascination  for  him,  and  led  him  not  only  to  use  many 
words  not  in  common  or  general  use  in  his  addresses  and  writings, 
but  also  aided  him  greatly  when,  as  often  happened  in  later 
years,  he  desired  to  coin  new  words  to  express  new  ideas,  new 
classifications  or  new  connotations. 

Dr.  Southard  was  very  decided  in  his  view  that  brain  diseases, 
insanities  and  dementias  as  well  as  others,  should  not  be  con- 
sidered simply  as  disorders  of  the  nervous  system,  but  as  dis- 
orders of  the  body  as  a  whole.  In  every  insanity  the  whole 
body  should  be  examined  and  considered.  It  was  partly  in 
connection  with  this  very  strong  feeling  that  he  published  in 
1914-15  his  article  "On  the  Nature  and  Importance  of  Kidney 
Lesions  in  Psychopathic  Subjects." 

He  worked  vigorously  during  these  years,  1914-16,  and  pub- 
lished several  articles  on  conditions  in  dementia  prsecox  and  in 
manic-depressive  insanity;  also  in  epilepsy,  which  he  had  for  many 
years  carefully  studied. 

In  1916  came  his  "  Stratigraphical  Analysis  of  Finer  Cortex 
Changes  in  Certain  Normal-looking  Brains  in  Dementia  Prsecox." 

In  1917  he  published  ten  papers. 

In  1918  his  very  important  paper  on  classification  of  disease 
for  diagnosis,  "Diagnosis  per  Exclusionem  in  Ordine"  appeared; 
also  "The  Kingdom  of  Evil,"  which  has  been  of  great  sugges- 
tiveness. 

From  1916  onward  Dr.  Southard's  interests  broadened  and 
widened  and  his  work  extended  in  many  different  directions. 

While  still  working  at  neuropathology  in  the  narrower  sense, 
and  studying  the  minute  anatomy  of  the  brain  in  dementia 
prsecox  and  manic-depressive  insanity,  epilepsy,  etc.,  he  was 
formulating  ideas  in  relation  to  the  conclusions  to  be  drawn  from 
the  facts  thus  obtained.  He  was  also  working  in  many  other 
directions. 

I.  In  collaboration  with  Dr.  Fernald  he  undertook  the  pub- 
lication of  a  work  on  "The  Brains  of  the  Feeble-Minded,"  and 
Part  I  of  this  was  published  in  1918.  It  may  be  fairly  stated  that 
this  is  the  first  scientific  work  carried  out  with  all  the  newer  and 
more  exact  means  of  research  on  the  brains  of  the  feeble-minded. 
(Part  II  of  this  work  is  almost  finished  and  shortly  to  be  pub- 
lished.) 

II.  He    conducted    investigations    into    the    psychology    and 


12 

mental  states  of  employees  in  various  factories  and  establish- 
ments, showing  how  the  knowledge  of  specialists  in  his  line  could 
be  applied  to  great  advantage  in  the  choice  and  adaptation  of 
workers,  thus  entering  the  subject  of  industrial  hygiene,  and 
proving  its  close  connection  with  the  studies  of  neuropathology. 

III.  In  his  work  at  the  Psychopathic  Hospital  he  had  insti- 
tuted a  psychiatric  social  service.  In  this  he  was  much  in- 
terested, and  in  several  papers  he  explained  what  this  service 
was,  what  its  value,  and  how  it  was  differentiated  both  from 
ordinary  social  service  work  and  from  psychiatric  nursing. 

In  his  later  years  Dr.  Southard  felt  that  the  time  had  arrived 
when  it  was  advisable  for  him  to  place  his  knowledge  before  the 
profession  and  others  in  books  rather  than  in  more  or  less  fugitive 
articles.  He  therefore  devoted  his  attention  to  writing  these, 
usually  in  collaboration  with  some  one.  Of  these  books  two  have 
been  published:  "Neurosyphilis,"  with  Dr..  H.  C.  Solomon,  in 
1917,  and  "Shell  Shock,"  in  1919.  He,  however,  had  in  mind 
other  books  at  the  time  of  his  death,  and  some  of  these  were 
far  enough  along  to  enable  us  to  hope  for  their  future  publica- 
tion. 

Dr.  Southard  was  a  neuropathologist,  and  all  his  work  and 
interests  centered  around  neuropathology  as  he  understood  it. 
Neuropathology,  to  his  mind,  comprised  much  more  than  the 
mere  cutting  of  sections  and  examining  them  microscopically,  or 
even  the  deducing  of  great  and  fundamental  facts  from  them. 
It  embraced  all  or  any  research  or  work  which  bore  on  or  related 
to  the  action  of  the  nervous  system  to  its  environment  in  health, 
or,  more  especially,  in  disease.  All  his  other  work  was  subsidiary 
to  this  central  idea.  But  his  other  work  in  various  lines  was  so 
excellent,  so  valuable  and  so  dominating  that  he  has  been 
variously  claimed  as  a  philosopher  or  psychologist,  as  a  social 
worker  par  excellence,  as  an  industrial  health  worker  and  as  a 
psychiatrist,  and  in  each  of  these  departments  it  has  been  said 
that  he  belonged  to  that  department  pre-eminently.  In  reality, 
all  this  work  in  these  lines  was  secondary  or  collateral  to  his 
great  aim,  —  the  knowledge  of  the  formation  and  character 
of  the  nervous  system  in  disease,  and  its  relations  in  the  internal 
and  reactions  to  the  external  world.  The  unusual  amount  of 
work  which  he  accomplished,  and  the  energy  and  enthusiasm 
which  he  showed  in  working  on  these  various  problems  which 
were  all  correlated  in  his  mind,  is  the  excuse  for  the  point  of 
view  of  the  separatists.     He  has  written  150  articles.     He  had  at 


13 

the  time  of  his  death  seven  books  in  his  mind,  most  of  them  in 
some  degree  of  preparation. 

I  have  not  entered  here  into  any  description  of  his  peculiar 
abilities.  He  had  remarkable  powers  of  deduction,  and  in  addi- 
tion he  had  an  extraordinary  and  most  unusual  capacity  to  per- 
ceive the  salient  fact  and  the  conclusions  to  be  drawn  or  which 
were  suggested  by  any  series  of  facts.  A  paper  written  by  an 
assistant,  which  seemed  to  be  stupid,  useless  and  uninteresting, 
became  under  his  hand  both  valuable  and  illuminating  because 
the  important  facts  were  brought  out  and  placed  clearly  before 
the  reader. 

Dr.  Southard  died  in  New  York  City  of  pneumonia,  Feb.  8, 
1920.  He  left  a  wife,  Dr.  Mabel  Austin  Southard,  to  whom  he 
was  married  in  1906,  and  three  children,  —  Austin,  Ordway  and 
Anne. 


14 


AN    APPRECIATION    OF    ELMER    E.    SOUTHARD.1 

By  Richard  C.  Cabot,  '89. 

Prodigious  personal  energy,  such  as  radiated  from  Ernest7 
Southard,  often  clothes  itself  in  a  hard  dour  exterior,  like  a  steam 
engine  or  a  fighting  bull.  But  the  peculiarity  of  this  great  psy- 
chiatrist was  that  he  was  always  bubbling  over  with  merriment. 
No  one  more  ready  to  laugh,  though  no  one  took  the  world  more 
seriously,  if  incessant  systematic  industry  is  a  mark  of  serious- 
ness. Such  childlike  merriment  is  not  the  common  mien  of 
those  who  spend  their  lives  in  laboratory  research  and  in  contact 
with  the  insane.  The  rollicking  joviality  of  his  boyhood  might 
well  have  left  him  altogether  when  he  settled  himself  to  hour 
after  hour  of  microscopic  work  on  the  shrunken  brains  of  feeble- 
minded children.  How  could  he  keep  his  sparkling,  rosy-cheeked 
good  humor  despite  his  contact  with  the  black  despairs,  or  the 
vacant-minded  animality  of  the  insane? 

Harvard  is  the  answer.  At  Harvard  he  struck  his  roots  so 
deep  in  the  solid  ground  of  philosophy  that  he  could  live  face  to 
face  with  the  saddest  and  most  discouraging  of  all  human  ex- 
periences —  feeble-mindedness  and  insanity  —  and  yet  preserve 
not  merely  a  stoic  calm  but  an  irrepressible  happiness.  He  came 
to  Harvard  with  no  social  prestige,  with  no  capacity  for  ath- 
letics, with  no  single  advantage  except  a  leaping  and  brilliant 
mind,  which  till  then  had  never  found  itself  an  asset.  He  had 
always  loved  to  think  and  read,  but  it  came  to  him  at  Harvard, 
with  a  shock  of  delighted  astonishment,  that  there  was  some- 
thing of  real  value  in  the  possession  of  an  active  mind. 

His  brilliancy  in  chess  first  brought  this  home  to  him.  Finding 
himself  intercollegiate  chess  champion  and  one  of  the  best  am- 
ateur chess  players  of  the  country,  he  began  to  realize  that  he 
could  achieve  a  standing  by  means  of  what  came  easy  to  him. 
He  did  not  discover  philosophy  at  the  outset  and  thought  that 
he  could  find  what  he  wanted  in  the  study  of  comparative  gram- 
mar! Strange  point  of  attack  on  life,  it  seems,  for  an  apparently 
care-free  undergraduate,  but  quite  easily  understood  when  we 
see  what  he  was  groping  for.  He  was  fascinated  by  the  psycho- 
logical suggestion  of  the  active  and  passive  voices,  the  subjunc- 

1  Reprinted  from  "The  Harvard  Graduates'  Magazine." 


15 

tive  mood.  In  later  life  he  was  prone  to  express  his  objections 
to  the  Freudian  psychology,  to  the  Hebrew  temperament  and  to 
the  deterministic  prejudice  of  psychiatrists  by  saying  that  they 
were  exclusively  in  the  passive  voice.  And  only  a  few  hours 
before  his  death  he  remarked  with  a  twinkle  to  a  companion, 
when  his  nurse  forced  him  to  observe  some  detail  of  sick-room 
routine,  "You  see,  F.,  we  are  now  in  the  passive  voice." 

But  he  was  not  so  in  college.  His  actively  inquisitive  mind 
soon  found  that  not  with  the  comparative  grammarians  but 
with  the  philosophers  he  was  at  home.  Thus  he  became  the 
ardent  student  and  follower  of  two  great  philosophers,  —  William 
James  and  Josiah  Royce.  Perhaps  the  catholicity  of  his  mind 
was  both  the  cause  and  the  result  of  this  unusual  devotion,  not 
to  either  alone,  but  to  both  of  these  strongly  contrasted  masters. 
Either  he  did  not  find  their  teaching  contradictory  or  he  grasped 
from  each  of  them  the  ideas  and  impulses  that  did  not  contra- 
dict each  other.  At  any  rate,  he  became  the  genuine  disciple 
of  each  of  them.  He  loved  and  revered  them  both.  To  carry 
on  their  work  and  propagate  their  ideas  was  a  large  part  of  his 
subsequent  life  work.  "I  give  that  course  in  psychopathology  in 
Cambridge,"  he  said  to  me  one  day,  "  mostly  as  tribute  to 
James,"  and  in  a  newspaper  interview  a  week  before  his  death, 
he  said,  apropos  of  "psychical  research,"  "In  the  first  place,  I 
must  explain  that  I  am  a  pupil  of  William  James,  and  that  I 
never  have  felt  that  I  wanted  to  differ  from  him  very  much  in 
any  of  his  beliefs  regarding  this  sort  of  thing."  Now  this  was 
said  in  the  present  tense  —  "I  am  a  pupil  of  William  James," 
despite  the  fact  that  Dr.  Southard  graduated  in  1897  and  had 
not  studied  with  James  for  at  least  twenty-three  years.  That 
is  the  spirit  of  actual  discipleship. 

The  degree  of  his  attachment  to  Josiah  Royce  may  be  im- 
agined when  we  realize  that  he  took  Professor  Royce's  Logic 
Seminary  year  after  year  for  thirteen  years;  indeed,  up  to  the 
time  of  Royce's  death.  During  five  of  those  years  I  was  in  the 
seminary  with  him,  and  so  am  able  to  trace  to  that  source  many 
of  the  ideas  that  came  sprouting  out  later  in  his  medical  addresses, 
often  to  the  mystification  of  his  hearers. 

Both  his  masters  stimulated  and  fed  his  natural  craving  for 
research,  which  was,  I  think,  the  central  passion  of  his  life. 
Jubilation  at  the  birth  of  new  truth  seems  more  characteristic 
of  him  than  any  single  trait  that  I  know.  He  was  not  soberly 
pleased  with  a  new  idea.     His  mind  gamboled  and  capered  about 


16 

it  with  radiant  delight.  He  played  with  it,  turned  it  upside 
down  and  inside  out,  tossed  it  up  and  caught  it  again.  Some- 
times (alas !)  he  did  this  before  an  audience  —  discovered  the 
new  idea  there  before  their  eyes  (though  quite  invisible  to  them), 
and  proceeded  to  play  a  game  with  it  in  celebration  of  its  birth. 
New  ideas!  Then  why  not  new  words  to  clothe  them  properly? 
And  incontinently  he  would  coin  some  new  combination  of 
Greek  roots,  which  in  turn,  perhaps,  would  remind  him  of 
Charles  Pierce  (one  of  the  three  great  American  philosophers,  he 
thought,  and  certainly  one  of  the  most  abstruse).  A  flow  of 
reminiscent  metaphysics  would  gush  forth,  till  his  audience  was 
apt  to  think  he  was  laughing  at  them  instead  of  at  his  new-born 
idea. 

Probably  the  greatest  limitation  on  his  influence  was  thus 
stubbornly  entangled  with  his  best  and  central  characteristic,  — 
his  tumultuous  joy  in  new  truth,  new  facts,  new  plans.  Readers 
were  sometimes  repelled,  listeners  mystified  or  annoyed,  because 
new  truth  was  so  precious  to  him  that  he  must  celebrate  its 
appearance,  in  season  or  out.  Yet  this  ungoverned  rejoicing  was 
the  symbol  and  the  starting  point  of  his  creative  work.  Nothing 
in  him  was  more  precious  than  his  originality.  Nothing  stimu- 
lated so  much  the  latent  originality  of  his  fellow  workers.  His 
enthusiasm  for  research  and  his  joy  in  its  results  was  soon  to 
make  him  the  soul  of  a  new  institution  —  the  Boston  Psycho- 
pathic Hospital  —  and  the  originator  of  two  largely  new  pro- 
fessions. New  work,  new  projects  radiated  from  him  in  all 
directions. 

Yet  there  was  nothing  scattered  or  superficial  in  his  work.  His 
profundity  was  greater  than  his  brilliancy.  He  stuck  to  one 
tough  job  for  fourteen  years,  all  the  years  of  his  working  life  — 
the  study,  post  mortem,  of  diseased  or  defective  brain  tissues.  On 
this  task  his  hours  at  the  microscope,  added  together,  must  have 
totaled  several  years.  Sixty-two  published  papers  described  the 
results  obtained  in  this  study  alone.  Yet  they  were  but  the 
surmounted  foothills  of  the  mountain  of  work  planned  by  him 
on  this  subject  for  the  next  fifteen  years.  "I  would  like  to  find 
the  minimum  brain  machinery  with  which  speech  and  thought 
processes  get  performed,"  he  wrote  last  August  (answering  his 
own  question,  "With  the  war  over  what  for  me  to  do?"),  "and 
I  hold  that  a  proper  medical,  pedagogic,  physiological  and 
anatomical  study  of  feeble-mindedness  will  bring  this  ideal 
about  more  quickly  than  any  other  thing.     I  might  be  willing 


17 

to  spend  my  whole  life  on  this  problem,  feeling  that  a  knowledge 
of  feeble-mindedness  would  bring  a  knowledge  of  thought,  and 
thus  the  greatest  deepening  of  philosophy  of  which  I  personally 
am  capable." 

The  closing  phrase  —  the  ultimate  goal  of  the  whole  life 
effort  —  is  significant.  It  is  amplified  in  another  passage  from 
the  same  statement  of  his  future  plans:  "Perhaps  I  believe  that 
the  world  can  get  forward  most  by  clearer  and  clearer  definition 
of  fundamentals.  Accordingly,  I  propose  to  stick  to  tasks  of 
nomenclature  and  terminology,  unpopular  and  ridicule-provoking 
though  they  may  be."  He  was  aware  of  the  unfashionableness 
of  a  search  for  fundamentals,  but  this  did  not  deter  him  —  even 
stimulated  him,  perhaps.  "For  I  have  to  contend  with  a  deep 
desire  not  to  be  popular,"  he  wrote.  "I  would  like  to  understaud 
this  desire  not  to  be  popular  coupled  with  as  strong  a  desire  to 
stand  well  with  certain  people.  This  class  needs  defining.  The 
problem  is  linked  up  with  that  of  aristocracy  —  the  kind  that  I 
believe  in.  The  nearest  I  come  to  it  is  that  the  aristocracy  I 
like  is  that  of  people  who  want  to  dig  out  novelty.  Underneath 
this  I  seem  to  have  a  moral  motive,  a  confidence  that  whatever 
is  new  is  likely,  on  the  whole  and  in  the  long  run,  to  be  better 
than  what  we  have.  Otherwise,  what  is  the  good  of  time,  any- 
how?" 

Was  he  a  scientist  or  a  philosopher?  His  two  weighty  books 
(on  "Neurosyphilis"  and  on  "Shell  Shock")  are  certainly  scien- 
tific, as  are  the  great  majority  of  his  159  pamphlets,  reports  and 
monographs  thus  far  published. 

But  I  think  the  truth  is  that  he  had  learned  from  Royce  and 
James  the  true  relation  of  science  and  philosophy,  so  that  he 
could  use  either  as  he  needed  it,  or  subordinate  them  both  in  the 
art  of  psychiatry.  He  used,  served,  extended  and  revered 
physical  science.  But  he  avoided  its  passing  fashions,  and  never 
mistook  it  for  the  only  method  of  finding  truth  or  the  only  guide 
to  action.  He  used  the  biologic  point  of  view  in  his  thinking. 
But  he  was  never  hypnotized  by  the  German  fashion  of  applying 
it  indiscriminately  to  all  fields  of  thought.  The  scientific  fad  of 
determinism  never  fooled  him  because  he  knew  how  to  use  it 
and  when  to  lay  it  aside.  His  philosophic  training  under  men 
who  used  scientific  method  without  becoming  enslaved  by  it 
had  prepared  him  to  avoid  the  philosophic  pitfalls  into  which 
biologists,  psychologists  and  psychiatrists  are  apt  to  fall. 

But  this  is  something  new  in  his  field.      An  optimistic  psy- 


18 

chiatrist  who  believed  in  the  soul,  who  was  not  a  materialist  or  a 
determinist  and  therefore  not  a  Freudian  —  this  was  something 
quite  startling;  in  fact,  quite  scandalous,  some  thought.  For 
after  graduating  at  the  medical  school  in  1901  he  had  difficulty 
in  getting  a  position  as  assistant  in  pathology  at  one  of  our  great 
Boston  hospitals,  because  he  was  known  to  be  a  disciple  of 
Royce  and  James.  But  I  prophesy  that  his  fame  for  pure 
scientific  work  will  far  outlast  that  of  those  who  then  so  nearly 
rejected  him  for  the  crime  of  having  studied  philosophy. 

It  is  an  astounding  fact  that,  despite  the  characteristics  which 
I  have  described,  he  became  a  public  official,  and  held  office 
under  the  State  of  Massachusetts  for  fourteen  years,  from  1906 
till  his  death  in  February,  1920.  He,  a  philosopher,  a  research 
man  and  (in  his  own  sense)  an  aristocrat,  distrustful  of  legal  and 
governmental  methods,  an  outspoken  individualist,  was  yet  able 
to  enter  and  to  hold  public  office,  to  deal  with  politicians,  Legis- 
latures and  budgets,  and  to  get  his  work  done  and  still  keep 
smiling.  It  was,  he  said,  a  matter  of  technique.  "Father's 
word,"  said  his  little  son,  "is  technique,"  and  indeed  he  used  this 
word  with  catholicity.  I  have  heard  him  speak  of  the  technique 
of  dealing  with  Legislatures,  and  in  almost  the  next  sentence  of 
the  technique  of  Jesus  Christ. 

But  in  a  more  usual  and  limited  sense  he  used  the  technique 
of  the  pathologist  in  the  group  of  hospitals  for  the  insane  main- 
tained by  the  State  of  Massachusetts.  With  the  assistance  of 
Dr.  Myrtelle  M.  Canavan  he  studied  countless  autopsies  on 
patients  dying  insane  in  these  institutions,  and  pursued  the 
microscopic  study  of  their  brain  tissues  to  and  beyond  the  limit 
of  present  knowledge.  No  one  else,  his  assistants  tell  me,  was  so 
skillful  in  this  work  as  he.  He  could  find  what  every  one  else 
passed  over.  His  touch  was  minutely  sensitive  to  the  consistency 
of  brain  tissues,  his  eye  expert  in  microscopic  diagnosis.  This 
work  covered  at  first  the  whole  field  of  his  teaching  as  Bullard 
professor  of  neuropathology  at  the  Harvard  Medical  School,  and 
was  continued  up  to  his  death.  One  thought  of  him  then  as  an 
expert  in  the  study  of  the  dead  brain  —  healthy,  diseased  or 
defective.  He  studied  especially  the  supposedly  normal  brains 
of  persons  dying  insane,  and  tried  to  correlate  the  microscopic 
abnormalities  which  he  found  with  the  particular  delusions  of  the 
patient  during  life.  Thus  he  suggested,  for  example,  that  de- 
lusions of  hearing  (imaginary  voices,  bells,  etc.)  are  linked  with 
microscopic  disease  in  the  brain  centers  of  hearing. 


19 

Such  studies  as  these  filled  most  of  his  time  from  1902  to  1912. 
They  led  him  to  define  one  of  the  leading  issues  of  his  science  as 
the  difference  between  those  who  believed  that  mental  disease 
was  due  to  a  "brain  twist,"  a  psychological  derangement,  and 
those  who  believed,  as  he  did,  that  a  "brain  spot,"  a  diseased 
area  in  the  brain,  was  the  cause.  ("The  Mind  Twist  and  Brain 
Spot  Hypotheses  in  Psychopathology  and  Neuropathology." 
Psychological  Bulletin,  1914,  XI,  117.) 

But  he  quickly  began  to  make  his  own  ideas  tell  in  the  ad- 
ministration of  the  State  institutions  as  well  as  in  pathology.  He 
saw  the  deficiencies  as  well  as  the  latent  possibilities  of  the  re- 
mote and  isolated  State  institutions  for  the  insane,  and  began 
at  once  to  stimulate  the  men  working  there  along  the  broad  lines 
of  research.  He  established  between  the  Danvers  Hospital  and 
the  Harvard  Medical  School  "a  voluntary  but  close  co-operation 
in  neuropathology  which  continued  for  many  years.  He  linked 
together  the  different  State  hospitals  in  a  co-operative  research 
on  psychiatric  problems  that  has  continued  to  this  day." 

Any  one  who  had  known  him  only  by  his  published  work  up 
to  1912  might  have  pictured  Southard  as  destined  to  sit  con- 
tentedly on  a  laboratory  stool  with  his  eye  to  a  microscope  for 
the  rest  of  his  working  life.  But  in  that  year  the  State  of  Massa- 
chusetts showed  extraordinary  good  sense  by  appointing  him  direc- 
tor of  the  Boston  Psychopathic  Hospital,  a  new  institution  built 
near  the  Harvard  Medical  School,  and  intended  for  temporary 
care  of  patients  who  might  or  might  not  turn  out  to  be  insane, 
—  a  diagnostic  station  for  the  study  of  mental  defects  or  possibly 
mental  disease,  without  the  ponderous  shackles  of  legal  commit- 
ment. This  was  in  itself  a  novelty  and  an  important  improve- 
ment. But  a  still  more  original  feature,  adopted  at  Dr.  South- 
ard's suggestion,  was  an  out-patient  department;  that  is,  a  place 
to  which  patients  suspicious  of  their  own  mentality,  and  those 
whose  sanity  seemed  doubtful  to  parents,  friends  or  social 
workers,  might  be  brought  for  examination  and  diagnosis.  This 
department  he  put  under  the  charge,  not  at  first  of  a  psychiatrist, 
but  of  a  pediatrician,  Dr.  W.  P.  Lucas,  in  order  to  link  neuro- 
psychiatry into  close  union  with  general  medicine. 

The  insane,  the  feeble-minded,  the  alcoholic,  drug  habitues, 
cranks,  "  queer  people,"  geniuses,  criminals  whose  acts  suggested 
a  "brain  spot  or  a  mind  twist,"  doddering  ancients  near  the  edge 
of  insanity  yet  oftentimes  not  insane,  people  with  disease  of  the 
kidney,  the  thyroid  or  other  organs  capable  of  producing  mental 


20 

symptoms  by  poisoning  the  whole  body  and  brain,  germ  diseases 
with  brain  symptoms,  —  these  and  many  others  came  to  the  out- 
patient department  of  the  new  Psychopathic  Hospital. 

To  this  influx  of  heterogeneous  misery  can  be  traced  four  in- 
ventions which  Dr.  Southard  has  left  us  to  carry  on.  New 
resources  were  called  for  if  such  a  multifarious  assortment  of 
living  problems  was  to  be  met,  studied  and  (to  the  limit  of 
knowledge  and  skill)  solved.  He  rose  to  the  greatness  of  the 
challenging  opportunity  and  evolved  four  new  ideas:  — 

1.  The  idea  of  the  neuropsychiatrist. 

2.  The  idea  of  the  psychiatric  social  worker  —  social  psy- 
chiatry. 

3.  The  diagnostic  scheme  of  the  Kingdom  of  Evil. 

4.  The  idea  of  orderly  exclusion  in  diagnosis. 

Each  of  these  (like  every  other  invention)  can  be  challenged 
as  not  wholly  new.  There  had  been  other  neurologists  who 
understood  psychiatry  also  (the  mind's  diseases  as  well  as  the 
nervous  system),  but  few  if  any  who  considered  their  province 
to  be  the  whole  human  being  in  all  his  relations  and  aspects!  Not 
diseases  of  the  mind  and  nervous  system  only,  but  all  bodily 
diseases  which  could  affect  the  mind;  not  disease  alone,  but 
congenital  defect  or  feeble-mindedness  which  is  ordinarily  studied 
by  specialists  in  that  defect  alone;  moreover,  the  effect  of  old 
age,  the  character  defects  due  to  bad  training,  to  economic  evils, 
to  "gangs,"  the  whole  problem  of  delinquency,  of  litigation  and 
its  attendant  evils,  of  unemployment  or  wrong  employment  when 
it  upsets  mental  or  moral  health,  —  all  this  was  the  field  of  the 
neuropsychiatrist  such  as  he  had  set  himself  to  become. 

Why  attempt  to  cover  such  an  enormous  area?  Because  all 
these  problems  presented  themselves  at  his  hospital  door,  and 
because  in  a  single  patient  all  or  nearly  all  of  them  might  need 
to  be  inquired  into  and  excluded  one  by  one  until  the  diagnosis 
of  one  sufferer's  troubles  was  found.  The  feeble-minded  man 
might  be  also  alcoholic,  syphilitic,  delinquent,  insane  or  merely 
abused  by  his  family.  There  could  be  no  sorting  out  or  passing 
round  of  such  an  individual  into  various  clinics  without  great 
"loss  of  motion"  in  the  process. 

Of  course  the  interest  of  such  a  profession  was  as  great  as  its 
area.  It  developed  all  sides  of  the  doctor  in  order  that  he  might 
investigate  all  sides  of  the  sufferer.  It  brought  him  in  touch 
with  all  the  queer  people  interested  in  the  hospital's  still  queerer 
patients.     It  forced  his  mind  across  the  professional  boundaries 


21 

of  medicine  and  made  him  a  leader  in  the  movement  of  our  time 
against  the  inhumanly  narrow  specialism  of  twenty  years  ago. 

But  he  was  too  wise  to  try  to  do  everything  himself.  He  as- 
sociated himself  with  Dr.  H.  C.  Solomon  in  a  masterly  and 
original  book  on  "  Neurosyphilis."  Moreover,  he  soon  found  out 
that  parts  of  his  job  could  be  done  better  by  women.  The  natural 
ups  and  downs  of  a  woman's  moods,  the  plasticity  of  her  sym* 
pathies,  fitted  her  better  than  the  rest  of  us  (he  believed)  /o 
enter  into  the  mental  and  moral  intricacies  of  his  patient,  and 
especially  into  his  domestic  life,  into  the  school  life  of  children 
and  the  whimsies  of  the  eccentric.  When  properly  trained  in  the 
rudiments  of  psychiatry,  a  sensible  and  sympathetic  woman 
could  follow  up  the  clues  hit  upon  by  the  doctor  in  his  first 
examination  of  the  patient,  bring  back  fresh  data  from  study  of 
his  home,  his  school  or  his  work,  and  so  contribute  to  a  well- 
balanced  and  accurate  diagnosis.  Moreover,  she  could  do  much 
to  carry  out  the  re-education,  the  family  readjustments*  and  the 
institutional  treatment  which  issued  from  the  diagnosis. 

Thus  was  born  the  idea  of  the  psychiatric  social  worker  as 
established  by  him  at  the  Psychopathic  Hospital  and  in  the  other 
State  hospitals  for  the  insane.  Like  his  idea  for  an  out-patient 
department  for  psychiatric  cases,  this  new  profession  was  not 
wholly  new,  yet  it  was  at  first  ridiculed,  and  then  partially 
though  widely  adopted  by  the  old-line  members  of  his  profession. 
He  was  constantly  reproached  for  his  innovations,  and  as  con- 
stantly imitated  in  them.  Finally  Smith  College,  in  the  summer 
of  1918,  gave  him  the  opportunity  to  establish  the  first  school 
for  psychiatric  social  workers.  The  sixty  enthusiastic  graduates 
of  this  school  were  intended  originally  for  war  work  with  "shell- 
shocked"  soldiers,  but  have  since  then  found  plenty  of  oppor- 
tunities open  to  them  in  civilian  institutions.  In  this  course  he 
was  but  one  of  many  teachers;  yet  the  alnmnse  considered  and 
named  him  "the  Father  of  our  Course." 

Contact  with  the  social  aspects  of  his  patients'  troubles  and 
with  the  psychiatric  social  case  studies  undertaken  by  Miss  Mary 
Jarrett,  took  him  far  into  the  field  of  social  work.  He  read  Miss 
Richmond's  masterly  book,  "Social  Diagnosis,"  and  was  led  to 
attempt  a  new  diagnostic  classification  of  all  the  evils  that 
poured  pell-mell  into  his  hospital  in  the  persons  of  his  patients. 
Like  all  his  classifications,  this  had  .practical  ends,  —  thorough- 
ness, order  and  the  saving  of  time./  The  Kingdom  of  Evil,  as 
he  saw  it  in  his  day's  work,  consisted  of  — 


22 

1.  Disease  (physical  or  mental). 

2.  Ignorance  (or  error). 

3.  Character  defect. 

4.  Legal  entanglements  (delinquency,  litigation). 

5.  Poverty  (or  resourcelessness  of  some  type). 

To  study  anybody's  troubles,  anybody's  melancholy,  revolt  or 
weakness  one  must  ask,  first,  is  it  due  to  disease  (for  disease  is 
the  commonest  and  the  most  easily  attackable  of  such  evils). 
Next,  is  it  due  to  misinformation,  deficient  information  or  mis- 
interpretation of  fact?  For  this  sort  of  trouble  next  to  disease 
it  the  simplest  to  deal  with.  If  neither  of  these  evils  can  be 
found,  character  defect  and  legal  entanglement  must  be  sought 
for,  Finally  (because  it  is  least  common),  we  may  ask  whether 
pur?  economic  defect  is  the  root  of  the  evil.  The  evils  of  poverty, 
he  believed,  can  be  shown  to  be  due  in  almost  every  case  to  dis- 
ease, ignorance,  character  defect  or  litigation.  Pure  poverty,  asa 
correct  social  diagnosis,  he  very  rarely  found.  Yet  if  the  orderly 
search  ?or  the  other  evils  is  not  undertaken  first,  poverty  may 
stand  out  so  as  to  become  not  merely  an  element  (as  in  the  80 
cases  listed  below),  but  the  only  diagnosis.  Then  economic  relief 
may  be  given,  with  harm  as  a  result. 

Classified  in  this  way  he  found  in  a  preliminary  survey  of  430 
problems  studied  at  the  Psychopathic  Hospital  72  of  disease, 
16  of  ignorance,  157  of  character,  105  of  legal  difficulty  and  80  of 
poverty. 

At  the  time  of  his  death  he  had  just  begun  to  attack  these 
problems  in  detail.  A  book  entitled  the  "  Kingdom  of  Evil," 
written  by  him  in  conjunction  with  Miss  Mary  Jarrett,  was 
nearly  finished,  and  will  be,  I  hope,  published  shortly. 

In  family  difficulties  he  wished  to  find  out,  first  of  all,  "  Who 
dominates  this  family?"  For  through  the  dominating  member, 
he  thought,  suggestions  could  best  be  introduced  and  improve- 
ments wrought.  "You  will  find  some  families  dominated  by 
the  mother  —  matriarchal,  we  might  call  them.  Others  are  of 
the  patriarchal  type;  the  father  dominates.  But  in  my  family 
the  daughter  is  the  central  figure."  (Whereupon  he  proceeded 
to  coin  a  new  word  denoting  domination  by  the  daughter.) 

"Then  we  need  to  know  how  many  parties  there  are  to  a 
quarrel  —  how  many  opposing  points  of  view.  There  are  rarely 
more  than  three.  The  situation,  as  we  find  it,  is  usually  duadic. 
There  is  the  father's  point  of  view  versus  the  mother's;  or  the 
parents'    arrayed   against   the    daughter's.      The   other   children, 


23 

friends  and  relatives  usually  espouse  one  or  the  other,  so  that 
their  testimony  is  merely  cumulative.  But  the  social  worker's 
own  view  may  well  be  different  from  either  of  those  existing 
before  she  came  into  the  problem.  Then  the  situation  becomes 
triadic.  Beyond  that  you  will  rarely  find  a  fourth  distinct  stand- 
point.    Three  is  usually  the  limit." 

In  pure  medicine,  none  of  his  ideas,  I  believe,  will  prove  more 
fruitful  than  that  of  "diagnosis  by  orderly  exclusion."  When  we 
hunt  through  our  pockets  for  a  letter,  we  pursue  the  diagnosis 
(where's  that  letter?)  by  exclusion.  We  search  one  after  another 
the  places  where  it  may  be  until  (perhaps)  we  find  it.  This 
method  is  also  used  in  medicine,  but  not  always  with  good  re- 
sults. For  the  diagnosis  may  be  in  none  of  the  pockets  investi- 
gated; perhaps  we  forget  an  out-of-the-way  pocket  (in  another 
suit,  possibly).  Dr.  Southard  proposed  a  plan  (a)  for  an  ex- 
haustive search  through  all  the  known  alternatives,  such  exhaus- 
tiveness  being  shielded  for  errors  of  memory  by  making  it  (b) 
orderly.  The  order  was  to  be  determined  by  various  practical 
considerations.  In  his  own  specialty  he  listed  the  best-known 
and  most  curable  diseases  first.  This  involved  an  ordered  tabula- 
tion of  mental  disease  or  defect,  in  classes  and  subclasses.  Within 
some  one  (or  more)  of  these  the  diagnosis  must  lie,  in  case  it  lies 
anywhere  among  the  diseases  already  known  to  medical  science. 

Had  he  lived  and  continued  in  control  of  the  Psychopathic 
Hospital  he  would,  I  believe,  have  applied  in  the  examination  of 
all  out-patients  the  tabulation  of  "The  Kingdom  of  Evil."  Then 
if  the  evil  proved  to  be  of  the  nature  of  disease  he  would  have 
repeated  the  orderly  exclusion  with  his  finer-meshed  scheme  of 
psychiatric  classification. 

So  far  as  I  can  see,  no  one  has  a  right  for  the  future  to  use  any 
other  method  than  this  in  medical  and  social  case  work,  until  he 
can  point  a  better  one.  One  can  trace  in  it  both  the  pragmatism 
of  James  and  Royce's  passion  for  the  concept  of  order.  One  can 
see  also  an  example  of  Southard's  type  of  originality;  he  applied 
in  a  new  field  concepts  or  tools  of  method  taken  from  an  old  one. 
He  brought  grammatical  categories  (passive  voice,  subjunctive 
mood)  into  psychiatry.  He  applied  medical  logic  (diagnosis  by 
exclusion)  in  the  field  of  social  work,  and  so  invented  the  diag- 
nostic tool  called  the  "Kingdom  of  Evil."  He  brought  the 
methods  of  social  work  into  psychiatry,  and  combined  the  two  in 
the  psychiatric  social  worker.  All  this  was  a  peculiarly  Roycean 
idea.     Such  comparison  and  transference  of  concepts  from  many 


24 

fields  of  thought  was  the  central  topic  of  Royce's  Logic  Seminary, 
and  made  it  possible  to  draw  into  it  biologists,  mathematicians 
and  theologians  for  mutual  comparison  of  their  working  tools  and 
mental  processes.  Like  a  good  disciple,  Southard  carried  this 
master's  idea  into  new  fields. 

The  memory  of  his  other  master,  James,  urged  him  to  quite  a 
different  venture.  In  the  last  few  years  of  his  overflowing  life  he 
undertook,  under  a  grant  from  the  Engineering  Foundation,  to 
study  the  psychiatric  aspects  of  industry.  Carleton  Parker's 
work  interested  him.  Phenomena  like  the  I.  W.  W.  he  wished 
to  analyze  as  Parker  did  by  studying  the  men's  state  of  mind  and 
the  causes  which  produced  it.  Strikes,  excessive  "turn  over"  in 
industry,  the  different  types  of  labor  union  leadership,  could  be 
profitably  studied,  he  thought,  under  the  "cross  light  of  psychia- 
try." An  obsession,  a  queer  temperament,  a  mental  twist,  a 
psychopathic  personality,  might  explain  much  for  which  economic 
solutions  are  unsatisfactory,  and  so  might  give  us  the  key  to 
remedial  action.  He  had  not  time  to  go  far  in  this  direction. 
Hopes  and  plans,  not  fulfilments,  are  what  he  left  us  in  this  field 
which  he  thought  of  as  part  of  a  huge  and  shadowy  project  to 
which  he  and  others  gave  the  name  of  "the  mental  hygiene  move- 
ment." 

Mental  hygiene  was,  he  thought,  a  timely  way  to  attack  in  a 
fresh  spirit  the  ancient  problems  of  education  (secular  and 
sacred),  of  recreation,  family  life,  politics  and  social  reform. 
Ethics  was  for  him  best  attacked  as  mental  hygiene,  and  he  had 
planned  to  give  under  the  department  of  social  ethics  at  Harvard 
some  courses  which  in  one  of  his  last  letters  he  called  "Psychia- 
try and  social  ethics"  (or  simply  mental  hygiene).  I  often  asked 
him  what  was  really  known  about  mental  hygiene  in  the  more 
limited  and  ordinary  sense.  He  always  admitted  that  it  was  an 
empty  space  to  be  pre-empted,  rather  than  a  body  of  doctrine  to 
be  preached  —  a  hope  and  a  plan,  not  a  fact.  He  wanted  to 
attack  all  the  old  problems  in  a  new  way,  and  so  with  a  good  deal 
of  opportunism  he  caught  up  the  term  "mental  hygiene"  as  one 
conveniently  suited  to  the  mood  of  our  time.  Adopting  Dean 
Pound's  suggestion,  he  meant  to  divide  the  propaganda  for 
mental  hygiene  into  three  groups,  (a)  public  (or  governmental), 
(6)  individual,  and  (c)  (intermediate  between  the  other  two) 
social,  including  all  groups  such  as  colleges,  labor  unions,  clubs. 

He  was  somewhat  torn  between  his  propagandist  ideals  like 
mental  hygiene   and   his  research  ideals.     In   time  I   think  the 


25 

latter  would  have  conquered.  Yet  in  one  of  his  latest  writings 
his  propagandism  was  rampant  and  refreshing. 

"May  we  not  rejoice,"  he  wrote,  "as  psychiatrists,  that  we,  if 
any,  are  to  be  equipped  by  training  and  experience  better,  per- 
haps, than  any  other  men  to  see  through  the  apparent  terrors  of 
anarchism,  of  violence,  of  destructiveness,  of  paranoia  —  whether 
these  tendencies  are  shown  in  capitalists  or  in  labor  leaders,  in 
universities  or  in  tenements,  in  Congress  or  under  deserted  cul- 
verts. It  is  in  one  sense  all  a  matter  of  the  One  and  the  Many. 
Psychiatrists  must  carry  their  analytic  powers,  their  ingrained 
optimism  and  their  tried  strength  of  purpose  not  merely  into  the 
narrow  circle  of  frank  disease,  but,  like  Seguin  of  old,  into  edu- 
cation; like  William  James,  into  the  sphere  of  morals;  like  Isaac 
Ray,  into  jurisprudence;  and  above  all,  into  economics  and  in- 
dustry. I  salute  the  coming  years  as  high  years  for  psychia- 
trists."1 

He  was,  as  I  have  said,  a  great  disciple.  He  was  also  a  great 
gatherer  of  disciples.  Nearly  sixty  men  during  the  past  twelve 
years  have  worked  under  him  in  such  close  relations  that  each 
felt  him  nearer  than  any  other  friend.  Each  confided  to  Southard 
his  love  affairs,  his  financial  worries,  as  well  as  his  scientific  prob- 
lems. To  him  each  poured  out  his  soul  as  to  no  other,  and,  if  at  a 
distance,  kept  up  steady  correspondence  with  him.  Even  men 
who  had  been  with  him  but  a  few  hours  felt  themselves  his  in- 
timates. Part  of  this  devotion  was  due,  no  doubt,  to  his  utter 
freedom  from  jealousy.  When  men  working  under  him  used  his 
ideas,  accomplished  a  piece  of  work  and  got  credit  for  it,  he 
seemed  more  pleased  than  if  he  had  done  the  work  himself.  Part 
of  their  devotion  also  was  a  response  to  his  clear  sparkling  jubi- 
lant nature,  always  ready  to  go  full  speed  in  thought  or  work, 
whether  it  was  his  own  or  other's. 

He  was  too  kind  hearted  to  discharge  any  employee,  no  matter 
how  incompetent.  He  was  so  haunted  by  the  thought  of  a  moral 
downfall  precipitated  by  the  discharge  that  he  would  not  be 
responsible  for  it.  No  doubt  there  was  another  element  in  his 
leniency.  He  believed  that  his  psychiatric  training  ought  to 
make  him  able  to  get  on  with  people  with  whom  no  one  else 
could  get  on.  But  it  was  not  his  psychiatric  training  but  his 
power  of  rich  mental  association  and  his  hopefulness  that  made 
him  always  listen  so  patiently  and  attentively  to  any  idea  con- 

1  Presidential  address  before  the  American  Medico-Psychological  Association,  June  18,  1919. 
American  Journal  of  Insanity,  October,  1919. 


26 

fided  to  him  by  his  assistants.  "  He  could  so  easily  have  made  us 
feel  foolish,  but  he  always  listened  as  if  we  had  brought  him 
something  profound.  He  did  not  always  try  to  gloss  over  the 
superficiality  of  the  remark,  but  he  saw  lines  and  leads  in  it 
which  escaped  many  and  certainly  the  original  propounder." 

A  boyish  simplicity  was  natural  to  him.  He  had  no  conscious- 
ness of  dignity,  though  he  possessed  it,  and  almost  as  little, 
apparently,  of  his  body,  though  it  was  a  very  imperfect  one  in 
many  ways.  He  never  seemed  to  want  rest,  took  practically  no 
vacations,  worked  every  evening  and  every  Sunday,  and  was 
rarely  forced  to  miss  a  day  throughout  the  year.  Though  easily 
amused,  he  took  almost  no  recreation,  except  chess,  which  filled 
one  or  two  evenings  a  month.  With  this  and  his  work  and  the 
use  of  his  mind  in  floods  of  talk  and  discussion  he  had  all  the 
play  he  wanted.  His  idea  of  a  holiday  was  to  go  to  New  York 
and  shut  himself  up  in  a  library  where  he  could  get  in  fifteen 
hours  of  reading  uninterrupted. 

From  childhood  up  his  reading  was  voracious,  and  though  he 
rarely  read  the  whole  of  any  page,  he  seemed  to  miss  nothing. 
Recently  he  spoke  to  me  of  having  gone  through  the  whole  of 
George  Meredith's  novels  in  search  of  character  types  (the  sage, 
the  egoist,  the  silent  man).  On  another  occasion  he  had  re-read 
the  book  of  Job  to  find  examples  of  his  five  types  of  evil,  and 
galloped  through  a  bunch  of  law  books  to  catch  the  "spirit  of 
laws."  Yet,  despite  his  wide  ranging  generalizations  and  his 
innumerable  journeys  for  the  reading  of  papers,  he  never  lost  his 
grip  of  detail  or  his  capacity  for  minute,  laborious,  inductive 
work.  The  scholarly  elaboration  and  minuteness  of  detail  in  his 
last  two  books  makes  this  abundantly  clear. 

Resiliency  was  one  of  his  most  endearing  traits.  By  nature  and 
by  principle  he  was  bound  to  turn  every  misfortune  into  some 
particular  good,  so  that  in  the  end  it  would  be  better  than  if  the 
misfortune  had  not  occurred.  In  this  he  had  in  mind  Royce's 
doctrine  of  atonement.  "  To  use  the  psychopathic  by-products 
of  society  to  its  betterment,  a  sort  of  similia  similibus-  curantur 
idea,"  was  the  way  he  phrased  this  last  summer.  As  Mme. 
Montessori  derived  improvement  in  education  from  the  methods 
used  to  rouse  the  brains  of  the  feeble-minded  children,  so  he 
hoped  to  get  light  on  family  life  as  it  should  be  by  the  study  of 
families  containing  one  or  more  psychopathic  black  sheep,  and 
on  normal  psychology  by  studying  the  mind  diseased. 

When  dates  were  not  kept  or  specimens  spoiled  in  the  labora- 


27 

tory,  "It  doesn't  matter"  was  his  habitual  expression.  "Let's 
have  a  polychromatic  world,  not  a  monochrome."  Never  to  take 
a  passive,  an  oppressed,  a  down-hearted  or  disappointed  attitude 
was  a  principle  with  him.  Passivity,  he  held,  is  disease;  activity 
is  health.  Every  setback,  every  misfortune  set  him  scheming 
anew.  In  fact,  as  one  of  his  close  friends  said,  "  Surely,  he  must 
have  turned  his  own  death  to  some  advantage." 

He  made  some  enemies  by  the  directness  and  power  of  his 
attacks  on  what  he  regarded  as  abuses  or  entrenched  evils;  also 
by  his  habit  of  playing  with  ideas  before  an  audience.  "  But 
even  his  enemies  loved  him,"  one  of  his  disciples  told  me.  In  a 
world  no  more  Christianized  than  ours,  it  is  hard  to  think  of  a 
higher  tribute  than  that  remark. 

He  refused  to  make  money,  as  he  easily  could  have  done  by 
consultations  or  by  accepting  some  of  the  high-salaried  positions 
offered  him.  He  preferred  to  live  on  his  small  academic  and 
State  salary  because  this  allowed  him  time  for  the  research  work 
which  -he  wanted  most  of  all  to  do.  In  this  sacrifice  his  wife 
gladly  shared.  But  it  was  hard  for  them  both,  and  little  time 
was  left  for  family  life.  The  individuality  of  each  of  his  children 
was  precious  in  his  eyes.  Yet  on  that  very  account  he  was 
scrupulously  careful  not  to  interfere  in  their  free  development. 
"Sometimes  I  feel,"  he  wrote  last  summer,  "that  I  should  not 
try  to  influence  too  much  the  children,  —  the  poet  in  Austin, 
the  engineer  in  Ordway,  the  executive  in  Anne.  Should  they  not 
develop  themselves?"  It  was  safer  perhaps  to  control  family 
life  in  the  free  field  of  fiction.  "  I  have  an  idea  for  certain  novels 
which  would  contemplate  family  life  from  a  special  angle.  To 
execute  this  plan  would  mean  a  study  of  style  and  populariza- 
tion." Novel  writing  was  not  exactly  his  usual  business.  He 
had  never  attempted  anything  of  the  kind.  But  this  seemed  no 
obstacle  to  him.  He  regarded  it  merely  as  another  "technique" 
to  be  acquired.  The  only  difficulty  was  his  desire  (already  men- 
tioned) not  to  be  popular. 

His  religion  was  clear  and  personal.  He  had  a  strong  distaste 
for  organized  Christianity  and  worked  solidly  through  his  Sun- 
days. But  what  he  considered  the  essentials  of  Christianity  — 
among  them  the  crucifixion  and  its  significance  —  meant  a  great 
deal  to  him.  Still  more  intimate  and  pervasive  was  his  theism. 
He  hated  to  talk  or  hear  others  talk  of  such  matters  in  a  conven- 
tional or  hortatory  way,  or  even  with  emphasis  and  solemnity.  He 
did  not  wish  to  underline  his  words  on  any  subject,  but  especially 


28 

not  on  this.  The  casual,  off-hand  tone  was  his  favorite;  and  it 
was  while  shifting  the  logs  on  our  camp  fire  last  summer  that  he 
followed  up  some  rather  unflattering  expressions  about  "the 
church  deacon  type  of  personality"  by  suddenly  dropping  one 
end  of  a  log  and  holding  his  free  hand  close  above  his  head,  with 
the  brisk  remark,  "But  God's  always  right  there,  you  know." 
After  which  he  veered  swiftly  to  another  topic. 

He  believed  in  personal  immortality,  partly  from  the  influence 
of  his  two  revered  masters,  partly  from  his  own  experience. 
"You  know  I  believe  in  immortality,"  he  said  one  day. 
"James's  instincts  were  almost  always  right."  But  he  did  not 
wish  to  dwell  even  on  this.  "Of  course,  why  not?"  he  said, 
when  the  question  of  personal  immortality  was  raised  in  a  group 
of  his  medical  friends.  Because  it  was  a  matter  of  course  to  him, 
he  did  not  wish  to  stress  it.  He  used  his  beliefs  but  would  not 
boast  of  them.  A  healthy  mind,  he  thought,  will  not  pause  at 
such  a  point.  Lazy  self-complacency  and  sanctimoniousness 
might  result.  The  greater  the  idea  the  more  instant  its  demand 
for  activity,  for  new  ideas,  new  research,  new  propaganda,  such 
as  engaged  him  up  to  within  a  few  hours  before  his  death.  "In 
the  hot  fit  of  life,  a  tip  toe  on  the  highest  point  of  being,  he 
passes  at  a  bound  on  to  the  other  side.  The  noise  of  the  mallet 
and  chisel  are  scarcely  quenched,  the  trumpets  are  hardly  done 
blowing  when,  trailing  with  him  clouds  of  glory,  this  happy- 
starred,  full-blooded  spirit  shoots  into  the  spiritual  land." 


Curriculum  Vit^e  of  E.  E.  Southard. 

E.  E.  Southard  was  born  July  28,  1876,  son  of  Martin  and 
Olive  Wentworth  (Knowles)  Southard  of  Maine,  in  Boston, 
Mass. 

Graduate  (Franklin  medallist),  Boston  Latin  School,  1893. 

A.B.,  Harvard  College  (final  honors  in  philosophy),  1897; 
M.D.,  Harvard  Medical  School,  1901;  A.M.,  Harvard  Univer- 
sity, 1902.  Harvard  University  chess  champion,  1895-96  to 
1899-1900.     Doctor  of  science,  Georgetown  University,  1917. 

Student  interne  in  pathology,  Boston  City  Hospital,  1900-01. 
Assistant  in  pathology  and  assistant  visiting  pathologist,  Boston 
City  Hospital,  1901-05. 

Student,  Senckenberg  Institute  (Carl  Weigert,  Director)  Frank- 
fort, and  at  University  of  Heidelberg,  1902.  (Kraepelin's  clinics 
and  Nissl's  Laboratory.) 


29 

Instructor,  1904-05;  assistant  professor,  1906-09;  Bullard 
professor  of  neuropathology,  1909-20;  and  head  of  the  Depart- 
ment of  Nervous  and  Mental  Diseases,  1913-20. 

Assistant  physician  and  pathologist,  Danvers  State  Hospital, 
1906-09. 

Pathologist  to  the  Massachusetts  State  Board  of  Insanity,  later 
the  Commission  on  Mental  Diseases,  1909-19. 

Director  of  the  psychopathic  department  of  the  Boston  State 
Hospital,  1912-19. 

Director  of  the  Massachusetts  State  Psychiatric  Institute  under 
the  Massachusetts  Commission  on  Mental  Diseases,  1919-20. 

Associate  Editor  of  "Archives  of  Neurology  and  Psychiatry," 
"Journal  of  Nervous  and  Mental  Disease,"  "Journal  of  Clinical 
and  Laboratory  Medicine,"  "Journal  of  Abnormal  Psychology," 
and  "Bulletin  of  Massachusetts  Commission  on  Mental  Dis- 
eases." 

Member  of  the  American  Academy  of  Arts  and  Sciences,  Asso- 
ciation of  American  Physicians,  American  Association  of  Patholo- 
gists and  Bacteriologists,  Society  of  Experimental  Biology  and 
Medicine,  American  Medical  Association,  American  Association 
for  the  Advancement  of  Science,  American  Neurological  Asso- 
ciation, American  Medico-Psychological  Association,  National 
Association  for  the  Study  of  Epilepsy,  National  Association  for 
the  Study  of  Feeble-mindedness,  New  England  Psychiatric  So- 
ciety, Massachusetts  Medical  Society,  Boston  Society  of  Psychia- 
try and  Neurology. 

In  1906  Dr.  Southard  married  Dr.  Mabel  F.  Austin  who,  with 
two  sons  and  a  daughter,  survives  him. 

In  the  war  he  served  as  major  in  the  Chemical  Warfare  Divi- 
sion and  as  director  of  the  Boston  Unit  of  the  Army  Neuropsy- 
chiatric  Training  School. 

Books:  "Outlines  of  Neuropathology,"  1906  (J.  L.  Fairbanks 
&  Co.,  Boston);  "Neurosyphilis"  (with  Dr.  H.  C.  Solomon), 
1917  (W.  M.  Leonard,  Boston);  Shell  Shock  and  Neuropsychia- 
try," 1919  (W.  M.  Leonard,  Boston);  "The  Kingdom  of  Evil," 
1920  (to  appear). 

Monograph:  "Waverly  Researches  in  the  Pathology  of  Feeble- 
mindedness." (Memoirs  of  the  American  Academy  of  Arts  and 
Sciences.) 


30 


BIBLIOGRAPHY   ARRANGED   BY   YEARS. 

1901. 

Southard,  E.  E.     A  Case  of  Glioma  of  the  Frontal  Lobe.     Med- 
ical and   Surgical  Report,  Boston   City  Hospital,   1901,   138. 

Remarks. 

A  series  of  fourteen  cases  warrants  merely  qualitative  notice. 

Frontal  gliomata,  judging  from  those  so  far  reported,  are  not 
large,  affect  spheroidal  shape  with  ill-defined  borders,  depend 
for  color  upon  contained  blood  (often  in  normal  channels  only, 
but  characteristically  in  areas  of  infiltration,  sometimes  in  shape 
of  blood-pigment),  and  exhibit  degrees  of  consistency  quite 
various,  but  usually  firmer  in  places  than  the  surrounding  tissue. 
Cysts  are  common.  Gross  signs  of  pressure  are  shown,  com- 
monly by  flattening  of  convolutions,  by  evident  bulging,  or  by 
internal  hydrocephalus  and  pressure-ring  about  cerebellum. 

So  far  as  origin  goes,  they  occur  in  the  white  matter  scarcely 
more  often  than  in  the  gray;  and  the  crucial  cases  where  epen- 
dymal  origin  is  indicated  are  few  (Pfeiffer,  Henneberg). 

Histologically,  the  pictures  are  occasionally  quite  nondescript 
(though  cases  where  the  resemblance  to  sarcoma  was  too  close 
I  have  excluded).  The  Spinnenzelle,  astrocyte,  or  what  with 
modern  technique  is  more  properly  a  cell  within  a  sort  of  cage 
of  fibrillse,  is  the  characteristic  finding.  In  the  absence  of 
fibrillar  there  must  always  remain  some  doubt  as  to  diagnosis. 
Examination  of  sarcoma  elsewhere  in  the  body  with  the  aniline- 
blue  connective  tissue  stain  always  shows  a  well-marked  fibrillar 
(collagenous)  intercellular  substance  or  a  reticulum.  By  this 
method  it  should  be  possible  to  differentiate  between  sarcoma 
and  cellular  glioma  of  the  brain.  Elements  simulating  ganglion 
cells  are  occasionally  found  (Baumann-Stroebe,  Neurath,  Bo- 
nome).  Lymphoid  infiltration  of  adventitia  is  found  (Buchholz, 
Sbuthard).  Gliosis  elsewhere  than  in  the  tumor  is  occasionally 
found.  Pressure-atrophy  with  loss  of  myelin  is  found  according 
to  the  area  destroyed. 

The  clinical  aspects  are  variable,  and,  so  far  as  they  do  not 
hang  upon  simultaneous  affection  (by  tumor,  by  direct  or  in- 
direct pressure)  of  the  adjacent  motor  and  (on  the  left  side) 
speech    areas,    almost    uninstructive.      Moria    (Witzelsucht)    and 


31 

"cerebellar"  ataxia  seem  the  nearest  to  positive  and  intrinsic 
symptoms;  but  these  are  certainly  inconstant.  Perhaps  the  best 
case  surgically  is  that  of  Obici.  The  most  luminous  diagnosis 
seems  to  be  that  of  Bruns.  Here  the  localized  pain  and  tympany 
conspired  with  the  ataxia,  of  cerebellar  type,  to  secure  good 
localization;  and  the  affection  of  the  motor  region  was  a  fortu- 
nate auxiliary,  especially  in  its  slightness.  The  diagnosis  was 
made  of  gumma  affecting  the  area  afterward  found  gliomatous. 
I  may  here  thank  Drs.  W.  P.  Bolles  and  H.  W.  Cushing  for 
the  clinical  records  of  the  case,  Dr.  J.  J.  Thomas  for  suggestions, 
and  Dr.  F.  B.  Mallory  for  kind  supervision  of  the  work. 

1903. 

Brinckerhoff,  W.  R.,  and  Southard,  E.  E.  Note  upon  Ery- 
thragglutinins  in  a  Cyst  Pluid.  Journal  of  Medical  Research, 
Boston,  1903,  IX,  28-32. 

Summary. 
The  cyst  fluid  exhibits  — 

1.  Hetero-erythragglutinins  for  — 

(a)  Rabbit. 

(b)  Dog. 

(c)  Guinea  pig  (delaj^ed). 

2.  Iso-erythragglutinin  for  one  man. 

3.  No  other  iso-erythragglutinins  in  cases  examined  (no  auto-erythrag- 

glutinin) . 

The  cyst  fluid  is  capable  of  developing  an  anti-erythragglutinin. 

The  patient's  serum,  though  equally  hemolytic  with  the  fluid, 
shows  no  agglutinative  power. 

The  rabbit  erythragglutinin  sustains  a  quantitative  relation  to 
the  amounts  of  corpuscles  agglutinated. 

A  definition  of  the  type  of  agglutinate  obtained  in  work  like 
the  above  may  serve  to  bring  out  more  clearly  the  value  of  the 
blood  corpuscles  in  the  study  of  agglutinins.  The  kind  of  aggre- 
gate observed  may  be  shortly  termed  poikilagglutinate  in  con- 
trast with  the  homoagglutinate  or  rouleau. 

Slight  acquaintance  with  the  red  corpuscles  shows  that  they 
clump  in  two  forms,  in  one  of  which  the  arrangement  might  be 
simply  termed  streptic,  in  the  other  staphylic.  But  these  terms 
are  scarcely  definite  enough,  as  further  examination  shows. 

In   the   streptic   type  they  adhere  rim   upon  rim    to   form   the 


32 

coinrows  or  rouleaux.  In  the  staphylic  type  they  adhere  by 
prominent  angles  upon  surfaces  of  apposition  which  are  acci- 
dental. In  the  rouleaux  the  elements  preserve  to  a  degree  their 
biconcavity.  The  corpuscles  may  remain  biconcave  in  the 
staphylic  aggregates,  but  they  may  be  variously  crenate, 
vesicular,  or  otherwise  distorted.  The  elements  of  a  rouleau 
are  alike,  whereas  the  unlikeness  in  the  elements  of  a  tridimen- 
sional clump  may  be  striking.  Thus  the  streptic  agglutinate  and 
the  clump  in  three  dimensions  might  be  more  strictly  termed,  to 
employ  the  usual  prefixes,  homoagglutinate  and  poikilagglutinate. 

Nevertheless,  though  the  elements  of  a  rouleau  tend  to  show 
biconcavity,  the  elements  of  the  poikilagglutinate  (such  as  one 
gets  in  experiments  like  the  above)  may  be  equally  normal 
looking.  Though  the  streptic  agglutinate  may  be  said  to  depend 
upon  shape  of  elements  with  change  of  surface  or  change  of 
ambient  fluid,  the  staphylic  agglutinate  is  formed  without  regard 
to  element  shape,  consistently  with  great  variety  in  surface 
character  of  its  units,  and  in  the  absence  of  its  usual  medium. 

Striking  molar  changes  in  surface,  certainly  involving  marked 
molecular  redistribution,  are  consistent  with  the  constant  and 
regular  occurrence  of  poikilagglutination.  But  these  changes  are 
so  many  and  so  various  (crenation,  vesicularity,  distortion, 
laking  tendency)  that  they  can  hardly  be  invoked  as  the  cause 
or  necessary  condition  of  the  clumping. 

The  phenomena  of  corpuscular  clumping  thus  serve  to  demolish 
in  a  simple  manner  those  theories  of  agglutination  which  regard 
surface  changes  as  the  essence  of  clumping  in  general.  That 
demolition  had  indeed  been  long  since  practically  accomplished; 
but  the  blood  corpuscles  seem  an  especially  fitting  weapon. 

The  foregoing  study  emphasizes  once  more  the  quantitative 
character  of  those  phenomena  of  which  hemoagglutination  is 
one  representative,  sets  forth  a  certain  advantage  in  studying 
the  blood  corpuscles  to  make  clear  the  nature  of  agglutination, 
and  indicates  the  desirability  of  further  work  upon  agglutinins 
and  similar  principles  of  natural  occurrence  in  pathological 
fluids. 


33 

Southard,  E.  E.  A  Case  of  Carcinosis  with  Secondary  Nodule 
in  the  Eye.  Boston  Medical  and  Surgical  Journal,  1903, 
CXLIX,  287-289. 

Pathological  Summary  and  Discussion. 

Anatomically  the  case  shows  carcinoma  of  prostate  with  ex- 
tension into  retroperitoneal  pelvic  tissues;  carcinoma  of  intestine, 
liver,  spleen,  lung,  mediastinum,  thoracic  cage,  pia  mater,  eye; 
general  arteriosclerosis;  chronic  interstitial  and  arteriosclerotic 
kidney. 

Histologically  the  carcinoma  is  fairly  constantly  composed  of  — 

(a)  Smooth  masses  of  cells  having  indistinct  borders  and  a 
cytoplasm  containing  clefts  or  vacuoles  in  which  lie  oval  vesicular 
nuclei  with  prominent  nucleoli. 

(b)  A  stroma  varying  extremely  in  amount  from  organ  to 
organ.  The  minor  differences  are  partly  ascribable  to  locus. 
Thus  the  finely  serrate  border  found  in  the  liver  depends  upon 
the  rapid  growth  of  the  tumor  in  the  parenchyma  of  that  organ; 
with  this  may  be  compared  the  smooth  lobular  growth  in  the 
lung.  The  growths  in  the  pia  and  in  the  eye  must  be  grouped 
together  from  their  tendency  to  the  papillary  form.  The  ten- 
dency to  hemorrhage  shown  by  the  pial  growth  is  remarkable, 
and  is  probably  due  to  local  compression  of  the  veins.  Notable, 
also,  is  the  choroidal  pigment  deep  in  the  stroma  of  the  nodule 
of  the  eye. 

From  anatomical  and  histological  evidence  alone  one  would 
scarcely  be  warranted  in  assigning  the  prostate  as  the  original 
focus  of  tumor  formation.  But  the  case  as  a  whole  —  taken 
clinically  as  well  as  pathologically  —  seems  to  warrant  interpre- 
tation as  a  case  of  carcinoma  of  prostate  with  multiple  metastases. 

1904. 

Southard,  E.  E.,  and  Roberts,  W.  F.  A  Case  of  Chronic 
Internal  Hydrocephalus  in  a  Youth.  Journal  of  Nervous 
and  Mental  Diseases,  New  York,  1904,  XXXI,  73-80. 

Southard,  E.  E.  Neuropathology:  Outline.  J.  L.  Fairbanks 
&  Co.,  Boston.     (See  also  1906.) 

Southard,  E.  E.  The  Central  Nervous  System  in  Variola. 
Journal  of  Medical  Research,  Boston,  1904,  XI,  298-300. 
(New  series,  Vol.  VI.) 


34 


Remarks. 
The  only  finding  in  the  nervous  system  which  can  be  regarded 
as  an  essential  part  of  variola  is  the  hemorrhagic  tendency  some- 
times seen  in  the  cortex  and  cord  in  variola  hemorrhagica.  The 
majority  of  cases  of  abscess,  meningitis,  otitis  media  with  sinus- 
thrombosis,  and  disseminated  myelitis  can  be  safely  attributed, 
in  the  light  of  present  knowledge,  to  secondary  infection  with  the 
streptococcus;  but  the  pneumococcus  is  occasionally  responsible. 
There  is  a  further  series  of  phenomena  the  causes  of  which  are 
obscure;  prominent  here  are  aphasia  (usually  of  muscular  origin), 
isolated  motor  paralyses,  neuritis.  The  most  constant  nerve 
finding  from  the  clinical  aspect  is  some  degree  of  delirium,  which 
is,  perhaps,  best  regarded  as  the  delirium  of  exhaustion.  Re- 
covery is  here  the  rule.  There  seems  to  be  no  reported  case  in 
which  the  cortical  state  can  be  regarded  as  the  cause  of  death. 
In  the  interpretation  of  terminal  deliria  the  possible  effects  of 
the  pushing  of  alcohol  in  the  treatment  must  not  be  forgotten. 

Southard,  E.  E.,  and  Sims,  F.  R.  A  Case  of  Cortical  Hemor- 
rhages following  Scarlet  Fever.  Journal  of  American  Medi- 
cal Association,  Chicago,  1904,  XLIII,  789-792. 

Remarks. 

The  conception  of  encephalitis  has  suffered  from  a  dearth  of 
adequate  descriptive  work.  The  systematic  treatment  has,  there- 
fore, not  kept  pace  with  that  of  inflammation  in  other  tissues. 
For  example,  it  was  possible  to  say  in  1886  that  we  can  as  yet 
present  no  unitary  picture  of  processes  which  culminate  in  brain 
softening,  if  we  except  those  which  result  from  vascular  changes. 
Yet  in  1904,  in  the  latest  systematic  treatise  on  encephalitis,  we 
hear  that  recent  distinctions  of  encephalitis  into  various  forms  are 
erroneous,  and  that  all  these  phenomena  can  be  produced  by  any 
appropriate  inflammatory  agents,  among  which  are  numbered 
the  organisms  of  meningitis  and  of  influenza,  embolism,  aseptic 
trauma,  corrosive  substances  and  heat.  It  is  probable,  however, 
that  further  study  will  make  clear  a  difference  in  the  effects  of 
members  of  this  series  of  agents. 

There  are  several  characteristics  of  the  lesion  produced  in  the 
brain  by  bacteria  or  their  toxins  which  serve  to  obscure  the  issue 
by  drawing  attention,  on  the  one  hand,  to  the  vascular  system, 


35 

and,  on  the  other  hand,  to  the  neuroglia.  Thus  a  recent  triadic 
division  of  encephalitis  into  1,  purulent;  2,  hemorrhagic;  3, 
hyperplastic,  is  based  on  the  predominance  in  the  histologic 
picture  of  suppuration,  diapedesis  and  hemorrhage,  or  secondary 
glia-cell  changes.  It  is,  however,  probable  that  all  these  pictures 
may  be  produced  by  identical  agents.  The  omnipresence  of  the 
meningeal  and  adventitial  phagocyte  has  contributed  toward  a 
false  unification  of  the  pictures  of  bacterial  and  those  of  mechani- 
cal origin. 

Herein  we  have  sought  to  bring  out  the  predominance  of 
hemorrhage  and  phagocytosis  with  destruction  of  cortical  tissue, 
—  the  focal  effect  of  meningeal  suppuration  in  a  case  of  subin- 
fection  with  the  aureus  during  convalescence  from  scarlet  fever. 
The  case  is  one  of  cortical  hemiplegia  caught  in  process,  and 
brings  out  the  now  frequently  exemplified  inflammatory  origin 
of  this  disease. 

Howard,  F.  H.,  and  Southard,  E.  E.  A  Case  of  Glioma  in  the 
Sella  Turcica.  American  Journal  of  Medical  Science,  Phila- 
delphia and  New  York,  1904.  (New  series,  Vol.  CXXVIII, 
679-686.) 

Remarks. 

The  report  may  be  summed  up  as  follows:  — 

A  new  growth  at  the  base  of  the  cranium  gives  rise  to  some- 
what characteristic  symptoms  ending  in  death  after  six  years. 
The  tumor  has  gradually  filled  the  interpeduncular  space,  giving 
rise  in  the  lower  optic  apparatus  to  certain  degenerations,  a  part 
of  which  are  complete,  a  part  still  in  process.  The  brain  at  large 
shows  little  reaction  save  a  subpial  gliosis,  perhaps  incidental  to 
the  heightened  intracranial  tension. 

The  nature  of  the  growth  is  in  question.  The  oldest  portion  of 
the  tumor  (judging  by  the  development  of  the  fibrillse)  is  in  the 
locus  of  the  posterior  lobe  of  the  pituitary  gland,  which  lobe  nor- 
mally contains  neuroglia  cells  developing  fibrillae.  The  rest  of 
the  tumor  contains  few  demonstrable  fibrillae,  and  could  scarcely 
be  differentiated  from  a  sarcoma.  It  is  probably  justifiable  to 
classify  the  case  as  one  of  glioma  developing  in  the  posterior  lobe 
of  the  pituitary  body.  We  are  not  acquainted  with  previously 
reported  cases  of  such  tumors.  Definite  proof  of  the  existence  of 
this  tumor  type  can  only  be  brought  when  some  fortunate  case 
shall  be  dissected  showing  such  a  growth  in  the  midst  of,  or 
patently  growing  from,  an  otherwise  normal  pituitary  body. 


36 


1905. 

Southard,  E.  E.  The  Neuroglia  Framework  of  the  Cerebellum 
in  Cases  of  Marginal  Sclerosis.  Journal  of  Medical  Re- 
search, Boston,  1905,  XIII,  487-498.  (New  series,  Vol. 
VIII.) 

Summary. 

The  tissues  of  the  human  cerebellum  show  characteristic  re- 
actions to  injury.  There  is  a  line  of  cleavage  in  the  normal,  and 
especially  in  the  macerating,  cerebellum,  in  the  layer  known  as 
the  layer  of  Purkinje  cells.  The  cells  of  this  layer  suffer  the 
maximum  injury  both  upon  impairment  of  blood  supply  and  in 
acute  diseases  like  tuberculous  and  pyogenic  leptomeningitis. 
The  death  of  the  Purkinje  cells  is  attended  with  a  loss  of  their 
processes,  so  that  the  outer  or  molecular  layer  also  tends  to  break 
down.  Severer  injury  destroys  not  only  the  Purkinje  cells,  but 
also  the  nerve  cells  known  as  the  granules  of  the  inner  or  granular 
layer.  Throughout  the  varying  degrees  of  such  injury  cells  of 
the  neuroglia  series  persist.  Neuroglia  cells  are  found  active  in 
foci  which  contain  no  nerve  cells. 

The  neuroglia  reaction  differs  characteristically  in  the  various 
layers  making  up  a  lamina.  In  the  medullary  center  there  is  a 
regular  and  homogeneous  gliosis  in  which  the  pre-existent  cells 
produce  fibrils  which  run  in  no  given  directions  and  form  a  felt- 
work.  In  the  other  layers  the  neuroglia  reaction  is  regular,  but 
is  not  homogeneous. 

The  neuroglia  reaction  of  the  marginal  layers  is  such  that  a 
quite  regular  stratification  is  preserved.  The  strata  of  a  sclerotic 
lamina  are  formed  of  fibrils  running  in  fairly  definite  directions. 
The  former  line  of  cleavage  is  replaced  with  a  line  of  cells  which 
produce  numerous  fibrils  forming  three  layers:  (1)  a  layer  of  fine 
fibrils  lying  flatwise  to  the  outer  limits  of  the  medullary  center; 
(2)  a  layer  of  fine  fibrils  external  and  at  right  angles  to  these, 
and  also  lying  flatwise  with  relation  to  ■  the  medullary  center; 
and  (3)  a  layer  composed  of  coarser  radial  fibrils  running,  verti- 
cally with  respect  to  the  medullary  center,  out  to  the  connective 
tissue  of  the  pia  mater.  Of  these  fibril  systems  the  first  to  de- 
velop is  the  mass  of  radial  fibrils  known  as  Bergmann's  fibers. 
It  is  now  possible  to  doubt  the  accuracy  of  Golgi  pictures,  which 
make  these  fibers  branch  from  cells  of  the  inner  layers.  Their 
true  cells  of  origin  lie  along  the  line  of  cleavage  in  a  cerebellar 
lamina. 


37 

Southard,    E.    E.      A   Case   of   Glioma   of   the    Pineal   Region. 

American     Journal     of     Insanity,    Baltimore,     1905,    LXI, 

483-489. 

Remarks. 
There  are  in  the  literature  somewhat  over  fifty  accessible  ob- 
servations upon  tumors  (and  cysts)  arising  in  the  pineal  region. 
Of  these  a  few  only  relate  expressly  to  glioma  or  gliosarcoma. 
No  plates  accompany  these  accounts,  which  in  the  main  antedate 
the  neuroglia  knowledge  of  the  last  decade;  and  there  is  no 
means  of  divining  the  intercellular  structure  from  descriptions 
of  cell-pictures  which  fit  the  diagnosis  equally  of  glioma  and 
of  sarcoma.  It  is,  nevertheless,  probable  that  a  number  of  these 
cases  were  truly  cases  of  pineal  glioma,  and  that  further  un- 
doubted cases  will  be  recorded  if  interest  can  be  stretched  to 
include  a  differentiation  of  the  intercellular  substances.  It 
is,  moreover,  plain  that,  if  there  be  a  type  of  psammoma  related 
to  the  sarcomata  or  endotheliomata,  there  exists  in  any  event 
also  a  type  of  sand  tumor  belonging  to  the  gliomata. 

Southard,  E.  E.,  and  Keene,  C.  W.  A  Study  of  Acute  Hem- 
orrhagic Encephalitis  (Staphylococcus  Pyogenes  Aureus). 
American  Journal  of  Medical  Science,  Philadelphia  and 
New  York,   1905.     (New  series,  Vol.   CXXIX,  474-491.) 

Resume. 

1.  The  staphylococcus  pyogenes  aureus  produces  in  the  meninges 
and  brain  substance  of  man  a  type  of  inflammation  in  which 
hemorrhage  is  prominent. 

The  picture  post-mortem  in  man  varies  from  red  softening  or 
multiple  ecchymosis  and  small  abscess  to  frank  and  sometimes 
voluminous  hemorrhage.  The  site  of  election  for  the  hemorrhagic 
lesions  is  the  subcortical  region,  supplied  by  the  long  or  medullary 
branches  of  the  cortical  vascular  system. 

The  histological  picture  varies  from  diapedesis  and  slight 
leukocyte  emigration  to  abscess  and  acutely  destructive  hem- 
orrhage with  phagocytosis.  Collections  of  mononuclear  cells 
phagocytic  for  cells  and  cell  detritus  often  quite  obscure  the 
acute  inflammatory  appearance  of  the  lesion. 

Six  fatal  cases  in  man  were  examined,  all  but  one,  cases  of 
general  infection  with  the  staphylococcus  aureus. 

A  history  of  antecedent  disease  was  the  rule.     The  syndromes, 


38 

which  were  chiefly  of  sudden  onset  and  rapid  course  (three  to 
fifteen  days),  were  pysemic,  meningitic,  or  cerebral  in  type.  The 
cases  of  slower  course  were  the  most  plainly  cerebral. 

2.  The  staphylococcus  pyogenes  aureus  produces  in  the  brains 
of  guinea-pigs  an  inflammatory  process  which  tends  to  subside 
within  a  limited  period  (two  weeks),  and,  as  a  rule,  remains 
without  clinical  signs  throughout. 

No  hemorrhages  other  than  miliary  perivascular  ones  were 
observed  in  the  guinea  pig.  The  lesions  are  seldom  grossly  evi- 
dent. 

The  cell  pictures  are  of  meningitis  (discernible  in  six  hours), 
ependymitis  (twelve  to  fourteen  hours),  and  exudation  into  the 
brain  substance  (twenty-four  to  forty-eight  hours). 

The  four  and  five  day  cases  show  numerous  cells  of  the  lympho- 
cyte series  as  well  as  mononuclear  cells  phagocytic  for  exudative 
cells.  Examples  of  such  phagocytic  cells  have  been  found  as 
early  as  twenty -four  hours  after  inoculation. 

The  exudation  into  the  meninges  is  discernible  earlier,  and  its 
traces  are  demonstrable  later,  than  are  the  processes  in  the 
ependyma  and  the  encephalon;  but  the  meningitis  is  never  so 
extensive  or  striking  a  process  as  the  encephalitis  or  the  cho- 
roiditis. 

In  two  weeks  to  a  month  there  is  little  sign  of  the  previous 
infection. 

3.  The  staphylococcus  pyogenes  aureus,  of  the  strains  and 
in  the  doses  experimentally  used,  produces  in  the  guinea 
pig  a  curable  encephalitis,  that  is  a  process  which  in  logic  is 
termed  reversible.  The  same  organism  produced  in  our  human 
cases  extensive  brain  lesions  which  surely  look  as  a  group  irrep- 
arable. Perhaps,  however,  there  are  in  man  also  certain  cases  of 
encephalitis  which  reverse  themselves,  and  which  in  their  course 
are  taxed  with  being  "functional"  diseases  and  furnish  "func- 
tional" symptoms  during  and  after  tissue  repair. 

We  wish  to  thank  Drs.  Mason,  Shattuck,  Sears  and  Coolidge 
for  the  use  of  their  clinical  records,  and  Drs.  Brinckerhoff, 
Thompson  and  Wolbach  for  the  anatomical  data  in  their  autop- 
sies. Drs.  Councilman  and  Mallory  have  looked  over  the  histo- 
pathological  work,  and  Dr.  W.  N.  Bullard  has  interested  himself 
in  its  neurological  aspect.  The  work  was  done  under  the  Bullard 
gift  to  the  pathological  department  of  the  Harvard  Medical 
School  for  1904. 


39 

Southard,  E.  E.  A  Case  of  Cholesterin  Stones  in  the  Brain 
and  Cord.  Journal  of  American  Medical  Association, 
Chicago,  1905,  XLV,  1731-1733. 

Summary. 
Male  of  fifty-six  years.  General  and  extensive  arteriosclerosis, 
extending  to  gross  involvement  of  some  secondary  branches  of 
the  circle  of  Willis.  Death  from  heart  failure.  Small  masses  of 
pure  or  almost  pure  cholesterin  crystals  in  several  parts  of  the 
cortical  and  central  ganglionic  gray  matter  and  in  the  white 
matter  of  the  spinal  cord.  Largest  mass,  2  centimeters  in  diame- 
ter, in  middle  of  left  lenticular  nucleus.  Thin  capsules  due  to 
fibrillary  overgrowth  of  neuroglia  surround  the  masses.  The 
relation  of  cholesterin  to  miliary  glioses  in  the  spinal  cord  may 
readily  escape  attention. 

1905,  1906. 

Bullard,  W.  N.,  and  Southard,  E.  E.  A  Case  of  Idiocy  in  a 
Child  with  Cystic  Hemispheres.  Medical  and  Surgical 
Report,  Boston  City  Hospital,  1905,  77-86.  Also  under 
title,  Cystic  Aplasia  of  the  Cerebral  Hemispheres  in  an 
Idiot  Child.  Journal  of  Medical  Research,  Boston,  1906, 
XIV,  431-438.     (New  series,  Vol.  XI,  272.) 

General  Summary  and  Remarks. 

1.  An  infant,  born  in  the  eighth  month  of  pregnancy,  one  of 
twins  (the  other  stillborn),  was  backward  in  development,  gave 
evidence  of  extensive  nervous  defect,  with  numerous  convulsive 
seizures,  and  died,  when  thirty-seven  months  old,  of  broncho- 
pneumonia. 

2.  The  autopsy  showed  gross  cerebral  changes.  The  ground 
plan  of  the  cerebrum  was  preserved,  but  the  substance  of  each 
hemisphere  was  largely  replaced  by  a  closed  cystic  cavity,  inde- 
pendent of  the  ventricles.  The  interiors  of  the  cystic  cavities 
were  traversed  by  delicate  strands  of  neuroglia  tissue.  The 
pyramidal  tracts  failed  to  develop.  The  cerebellum  had  devel- 
oped almost  normally. 

3.  The  nature  and  time  of  the  original  injury  cannot  be  ex- 
actly fixed.  The  agent  was  probably  focal  and  just  severe  enough 
to  destroy  the  nerve  cells  or  nerve  cell  producing  cells,  but  leave 
the  neuroglia  cell-series  intact  and  capable  ultimately  of  produc- 


40 

ing  fibrils.  The  effect  of  this  differential  aplasia  is  that  neuroglia 
tissue  alone  serves  to  maintain  much  of  the  ground  plan  of  the 
cerebral  cortex. 

4.  Although  the  original  injury  may  have  been  quite  limited  in 
extent,  the  failure  of  cell-processes  and  whole  fiber  systems  to 
develop  co-ordinately  with  the  expansion  of  the  cerebrum  has 
increased  the  ultimate  loss  of  solid  tissue  manyfold. 

5.  It  is  probable  that  the  cystic  chambers  in  the  cerebrum  are 
in  part  due  to  the  dilatation  of  perivascular  spaces,  with  eventual 
rending  apart  of  their  walls,  as  the  brain  plan  continues  to  en- 
large and  the  neuroglia  masses  contract.  There  are  phagocytic 
cells  in  recesses  along  the  fibrous  walls  of  the  cystic  spaces.  It 
is  not  clear  whether  the  neuroglia  tissue  or  one  of  the  brain 
envelopes  is  the  leading  tissue  in  the  enlargement  of  the  brain 
plan. 

6.  The  case  showed  very  little  thymus  tissue,  which  was  largely 
overgrown  by  cells  of  the  connective  tissue  series.  The  kidneys 
were  backward  in  development.  There  were  some  peculiarities  of 
the  spleen.  It  is  not  yet  possible  to  say  what  part  is  played 
herein  by  the  cerebral  defect. 

Southard,  E.  E.  A  Case  of  Potts'  Disease  in  the  Monkey. 
Medical  and  Surgical  Report,  Boston  City  Hospital,  1905, 
166-171.  Also  entered  in  1906  (exactly  same  title),  Journal 
of  Medical  Research,  Boston,  1906,  XIV,  393-398.  (New 
series,  Vol.  XI.) 

Summary. 

1.  A  half -grown  pet  macacus,  autopsied  several  weeks  after 
onset  of  paraplegia,  showed  tuberculosis  of  the  spleen  and  of  the 
lumbar  spine.  There  were  extra  dural  masses  opposite  the  upper 
three  lumbar  vertebrae,  together  with  penetration  of  the  dura 
and  compression  of  the  cord  at  the  second  lumbar  vertebra. 

2.  The  neuroglia  fibrils  in  Macacus  cynomologus  can  be  demon- 
strated well  by  the  use  of  the  phosphotungstic  acid  hematein 
method  after  fixation  in  Zenker's  fluid.  The  picture  approxi- 
mates that  of  the  human  cord  similarly  treated.  The  extent  and 
character  of  the  neuroglia  changes  found  in  this  case  suggest 
profitable  lines  of  experimental  work  on  cellular  and  fibrillary 
gliosis  in  the  monkey. 

3.  Areas  of  secondary  degeneration  in  this  case,  studied  com- 
paratively by  the  methods  of  Marchi  for  fat,  of  Weigert  for 
myelin,  and  of  Mallory  for  neuroglia  and  for  connective  tissue, 


41 

demonstrate  active  neuroglia  changes  with  new  fibril  formation 
in  an  early  stage  of  secondary  degeneration.  The  fatty  degenera- 
tion is  attended  with  fibrillary  gliosis,  the  onset  of  which  ante- 
dates a  demonstrable  loss  of  myelin. 

4.  The  connective  tissue  cells  in  degenerated  nerve  bundles  in 
the  cauda  equina  show  activity  analogous  to  the  neuroglia  cell 
changes  found  in  the  cord. 

Bullard,  W.  N.,  and  Southard,  E.  E.  A  Case  of  Diffuse 
Gliosis  of  the  Cerebral  White  Matter  in  a  Child.  Medical  and 
Surgical  Report,  Boston  City  Hospital,  1905,  19-25.  Also 
under  title,  Diffuse  Gliosis  of  the  Cerebral  White  Matter  in 
a  Child.  Journal  of  Nervous  and  Mental  Disease,  New 
York,  1906,  XXXIII,  188-193. 

Summary. 

1.  Boy  of  six  and  a  half  years.  Measles  at  three  years.  One 
year  before  death  fell  backward  down  three  steps  in  a  cellar, 
with  epistaxis,  and  possibly  bleeding  from  ear.  Afterward  "nerv- 
ous." A  month  later  began  to  stagger  in  walking,  became  grad- 
ually deaf  and  stupid,  later  blind  and  dumb.  Operation  for 
chronic  internal  hydrocephalus.  Death  two  days  after  opera- 
tion. 

2.  The  autopsy  showed  sclerosis  of  the  white  matter  of  the 
occipital,  parietal  and  temporal  lobes  on  both  sides  with  scle- 
rosis of  optic  thalami  and  of  small,  roughly  symmetrical  areas  in 
the  white  matter  of  the  cerebellum. 

3.  The  microscopic  examination  shows  a  cellular  and  fibrillary 
overgrowth  of  neuroglia,  sharply  limited  to  the  white  matter. 
The  picture  gradually  varies  from  that  of  masses  containing  giant 
cells  and  few  fibrils  to  that  of  active  fibril-producing  cell  masses 
or  that  of  stratified  areas  of  inactive  fibrillar  gliosis. 

4.  The  lesion  involves  the  destruction  of  myelin  sheaths  and 
considerable  axis-cylinder  material.  The  lesion  may  be  described 
as  a  multiform  gliosis  of  the  white  matter  with  extensive  mildly 
destructive  properties.  The  nutrition  of  the  areas  is  maintained. 
The  overgrowth  of  neuroglia  substitutes  for,  and  to  some  extent 
destroys,  the  involved  tissues,  but  fails  to  invade,  in  the  sense  of 
invasion  by  glioma.  The  overlying  cortex  fails  to  show  important 
changes.     The  origin  of  the  condition  is  unknown. 


42 


1906. 

Southard,  E.  E.  A  Case  of  Glioma  of  the  Frontal  Lobe  with 
Invasion  of  the  Opposite  Hemisphere.  American  Journal  of 
Insanity,  Baltimore,  1905-06,  LXII,  561-570. 

Summary. 

1.  Man  of  forty-one,  dying  ten  weeks  after  onset  of  symptoms 
pointing  to  cerebral  disease,  showed  three  apparently  discrete 
nodular  lesions  of  the  right  frontal  lobe,  one  of  which  had  pierced 
the  pia  mater  of  the  longitudinal  fissure  and  invaded  the  left 
rostral  convolution. 

2.  Examination  of  the  hemorrhagic  and  edematous  tissue  of 
the  medullary  center  beneath  the  nodules  showed  bands  of  tissue 
like  that  in  the  nodules.  If  the  tumor  started  from  one  focus  in 
the  medullary  center,  the  extent  and  character  of  the  lesion  may 
be  due  to  rapid  growth,  unequal  along  different  radii.  Throm- 
bosis accounts,  for  the  necrotic  and  cystic  center  of  the  mass. 

3.  The  tumor  is  a  glioma,  rapidly  growing  and  malignant  in  a 
sense  unusual  for  cerebral  gliomata,  in  that  it  invades  non- 
nervous  tissue. 

Southard,  E.  E.  Outline  of  Neuropathology  (revised  from  edi- 
tion of  1904).     J.  L.  Fairbanks  &  Co.,  Boston,  1906. 

Southard,  E.  E.,  and  Keene,  C.  W.  A  Study  of  Brain  Infec- 
tions with  the  Pneumococcus.  Journal  of  American  Medical 
Association,  Chicago,  1906,  XL VI,  13-21. 

General  Summary  and  Remarks. 
The  foregoing  is  a  report  of  cases  grouped  together  as  showing 
effects  of  pneumococcus  brain  infection.  The  clinical  and  ana- 
tomical varieties  which  they  exhibit  are  only  in  part  explained  on 
present  evidence.  A  long  series  of  cases  with  parallel  differential 
work  on  the  best  bacteriologic  lines  will  be  required  to  settle 
questions  brought  up  by  the  various  extent  and  effect  of  lesions 
like  arteritis  and  phlebitis,  by  the  varying  prominence  of  poly- 
nucleosis and  mononucleosis  in  the  meningeal  exudate,  by 
variation  in  the  phagocytic  properties  of  the  cells  involved,  and 
by  the  varying  extent  and  character  of  the  attendant  cellular 
gliosis. 


43 

Clinically  viewed,  these  cases  are  quite  ill  assorted.  The 
group  includes  fulminant  and  wholly  obscure  cases;  cases  not 
to  be  told  from  severe  pneumonia;  clearly  otitic  cases;  septi- 
cemic phenomena;  and  cases  a  week  old  or  longer  which  are 
clearly  cerebral  or  meningitic  in  character. 

Anatomically  viewed,  the  pneumococcus  produces  in  the 
meninges  and  brain  substance  of  man  a  type  of  inflammation  in 
which  cellular  exudation  and  fibrin  formation  are  prominent. 

The  picture  post-mortem  varies  from  focal  or  diffuse  red 
softening  to  purulent  leptomeningitis  and  ependymitis  and  occa- 
sionally abscess  formation.  The  meningeal  exudate  is  almost 
constant  on  the  convexit}'.  The  base  is  frequently  involved, 
and  with  the  base,  often  also  the  ventricles  and  the  cord. 

The  histologic  picture  is  more  various  than  the  anatomic 
picture.  The  meninges  contain  a  cellular  exudate  which  varies 
in  the  proportion  of  polynuclear  leucocytes  and  mononuclear 
cells.  Phagocytosis  on  the  part  of  mononuclear  cells  for  poly- 
nuclear leucocytes  is  best  marked  in  cases  in  which  the  mono- 
nuclear cells  outnumber  the  polynuclear  leucocytes.  The  meninges 
in  individual  cases  are  fairly  constant  in  the  cell  proportions  found. 
Fibrin  is  found  about  the  veins  and  adjacent  to  the  nerve  tissue. 

The  arteries  characteristically  show  lifting  of  the  endothelium 
by  cellular  exudate.  The  veins  often  show  proliferative  changes 
in  the  intima  with  infiltration  by  polynuclear  leucocytes  (char- 
acteristic in  large  sulcal  veins).  Two  cases  showed  mural 
thrombus  formation  in  the  veins. 

Seven  cases  out  of  twelve  showed  increase  or  other  signs  of 
change  in  the  neuroglia,  especially  of  the  subpial  layer. 

Penetration  of  the  cortical  tissue  by  polynuclear  leucocytes  is 
almost  constant. 

Orbital  inoculations  in  the  guinea  pig  showed  remarkable 
variety  in  the  results  with  different  cultures.  With  the  cultures 
yielding  positive  results  a  general  but  not  constant  tendency  is 
to  the  production  of  exudates  with  a  high  proportion  of  mono- 
nuclear cells  of  the  phagocytic  series.  A  series  of  orbital  inocu- 
lations with  culture  identical  throughout  exhibited  clearly  the 
same  tendency.  The  exudation  of  polynuclear  leucocytes  is 
primary,  however,  and  may  be  noted  in  six  hours.  The  exudate 
is  at  its  height  in  three,  four  or  five  days,  and  leaves  no  trace 
in  from  two  to  five  weeks.  Ependymitis  and  encephalitis  are  not 
prominent.  The  guinea  pig  inoculations,  as  a  rule,  produce  no 
clinical  sign. 


44 

Southard,  E.  E.,  and  Stratton,  R.  R.  A  Study  of  Acute 
Leptomeningitis  (Streptococcus  Pyogenes).  Journal  of 
American  Medical  Association,  Chicago,  1906,  XL  VII, 
1271-1277. 

General  Summary  and  Remarks. 

Cases  of  streptococcus  brain  infection  are  of  interest  in  com- 
parison with  the  cases  of  pneumococcus  brain  infection  described 
last  year.  The  main  results  may  be  stated  in  connection  with 
those  of  the  pneumococcus  study. 

As  with  the  pneumococcus  series,  the  questions  of  main 
interest  are  brought  up  by  the  varying  extent  and  effect  of 
lesions  like  (1)  arteritis  and  phlebitis,  (2)  the  cellular  infiltration 
of  the  meninges  with  its  variation  in  respect  to  phagocytosis, 
and  (3)  the  attendant  cellular  and,  in  certain  cases,  fibrillar 
gliosis. 

Clinically  viewed,  the  cases  are  of  various  duration  and  run 
a  trifle  longer  than  the  pneumococcus  cases.  The  relation  of 
streptococcus  meningitis  to  lung  lesions  is  less  suspicious  than 
that  of  staphylococcus  or  pneumococcus  brain  infections  to  lung 
lesions.  The  part  played  by  lung  lesions  in  bringing  about 
meningitis  has  probably  been  overestimated.  The  streptococcus 
cases  seem  to  be  more  pronouncedly  "cerebral"  or  "meningitic" 
from  the  very  start  of  acute  symptoms  than  are  the  pneu- 
mococcus and  staphylococcus  cases,  which  are  a  little  more 
"primary." 

Anatomically  viewed,  the  streptococcus  cases  preserve  their 
resemblance  to  the  pneumococcus  cases,  even  to  the  production 
in  some  cases  of  small  abscesses.  Particular  attention  may  be 
called  to  the  case  simulating  meningitis  serosa  (Case  4).  It 
would  be  well  to  review  the  cases  of  this  disease  to  be  found  in 
the  literature,  and  exclude  those  without  bacteriologic  exam- 
ination. 

Considered  histologically,  the  streptococcus  cases  again  re- 
semble the  pneumococcus  cases.  The  same  relations  of  bacteria 
to  leucocytes,  of  leucocytes  to  cells  of  the  macrophage  type  are 
shown  in  the  two  series.  The  intimal  infiltration  of  the  arteries 
and  the  intimal  proliferation  and  exudative  lesions  of  the  veins 
run  parallel  in  the  two  cases.  The  occurrence  of  early  fibrillar 
gliosis  (in  the  sense  of  the  production  of  new  fibrils  by  the 
swollen  neuroglia  cells)  is  important.  The  interpretation  of  early 
fibrillar  gliosis  is  not  easy,  since  it  is  necessary  to  exclude  ex- 


45 


traneous  causes  (eld  age,  arteriosclerosis,  chronic  active  lesions) 
for  its  occurrence. 

An  extensive  series  of  guinea  pig  inoculations,  which  need  not 
be  reported  in  detail,  confirmed  the  main  result,  viz.:  the  par- 
allelism in  action  of  the  two  organisms,  pneumococcus  and  strep- 
tococcus. Orbital  inoculations  simultaneously  in  numerous 
animals  with  histologic  examination  of  animals  killed  on  succes- 
sive days  were  employed  as  in  previous  work.  The  inoculations 
of  the  strains  used,  as  a  rule,  produced  no  clinical  sign,  despite 
the  suppuration  present.  As  in  the  human  cases,  each  of  the 
lesions  found  is  apparently  wholly  curable  taken  by  itself. 

The  reversible  character  (to  use  a  phrase  from  books'  of  logic) 
of  the  phenomena  is  shown  in  the  strikingly  various  pictures 
presented  by  the  exudate  in  Case  9  taken  from  the  vertex 
downward. 

Indeed,  it  is  rare  to  find  in  streptococcal,  as  in  other  forms 
of  acute  leptomeningitis,  any  single  lesion  which  is  necessarily 
incurable.  It  is  probable  that  in  many  cases  the  patients  die  of 
toxemia.  This  toxemia  may  vary  with  the  extent  of  the  exudate. 
The  amount  of  exudate  which  we  see  at  an  autopsy  may  mislead 
us  in  our  idea*  of  the  proportions  of  the  toxemia,  since  wide 
reaches  of  the  pia  mater  may  be  sterile,  though  other  parts 
contain  multiplying  organisms.  Differential  studies  of  the 
exudate  in  several  places  are  essential  if  we  are  to  get  a  fair 
sample  of  the  conditions.  Such  studies  might  readily  assume 
clinical  importance. 

The  early  glioses  found  in  several  cases  are  of  some  importance 
both  in  general  and  clinically.  These  glioses  will  be  best  con- 
sidered in  connection  with  those  in  tuberculous  meningitis  in  a 
subsequent  paper. 

Ruston,  W.  D.,  and  Southard,  E.  E.  Cerebral  Seizures  with 
Suboccipital  Pain;  Miliary  Cerebral  and  Gross  Vertebral 
Aneurysms.  Boston  Medical  and  Surgical  Journal,  1906, 
CLIV,  312-314. 


46 


1907. 

Southard,  E.  E.,  and  Hodskins,  M.  B.,  General  Encephalo- 
malacia.  (Abstract.)  Journal  of  Nervous  and  Mental  Dis- 
ease, New  York,  1907,  XXXIV,  267-268. 

Remarks. 

The  speakers  proposed  to  define  a  type  of  soft  brain  differing, 
on  the  one  hand,  from  encephalomalacia,  due  to  plugging  of 
vessels,  and,  on  the  other  hand,  from  autolytic  softening  of  post- 
mortem origin.  They  termed  the  condition  general  encephalo- 
malacia. The  condition  is  characterized  by  (1)  diffuse  axonal 
reactions  in  many  types  of  cell;  (2)  diffuse  fatty  degeneration 
demonstrated  by  the  Marchi  method;  (3)  absence  in  increase  of 
weight  (important  in  distinguishing  grossly  from  edema);  (4) 
absence  of  exudative  changes. 

Epileptics  are  somewhat  prone  to  exitus  with  soft  brain.  The 
condition  seems  to  be  associated  with  a  'terminal  exhaustion. 
The  illustrative  case,  that  of  an  epileptic  dying  at  forty-two,  was 
of  importance  in  that  it  showed  the  same  histological  changes  in 
the  midst  of  a  sclerotic  area  as  were  shown  by  the  remainder  of 
the  brain  and  cord.  Thus  the  lysis,  while  it  appears  to  be  a 
general  histolysis,  is  actually  a  differential  cytolysis  or  axonolysis. 
Enlargements  were  shown  from  photomicrographs  of  axonal  re- 
actions in  various  types  of  cell  from  the  illustrative  case. 

Southard,  E.  E.  Late  Epilepsy  in  a  Woman  over  Sixty  Years 
of  Age.  (Abstract.)  Journal  of  Nervous  and  Mental  Dis- 
ease, New  York,  1907,  XXXIV,  399.  Also  as  under  the 
title,  Diffuse  and  Focal  Lesions  in  a  Case  of  Late  Epilepsy. 
Transactions,  National  Association  for  the  Study  of  Epilepsy 
and  Care  and  Treatment  of  Epileptics,  1906,  IV,  131-145. 

Collins,  A.  N.,  and  Southard,  E.  E.  Gliotic  Cyst  of  the  Right 
Superior  Parietal  Lobule.  (From  the  Laboratories  of  the 
Boston  City  Hospital  and  the  Danvers  Insane  Hospital.) 
American  Journal  of  Insanity,  1907,  LXIV,  299-304. 

Remarks. 
We  have  to  deal  in  the  present  case  with  a  condition  of  cyst 
with  gliosis  in  the  right  superior  parietal  lobule.     The  cyst  was 
2.5    centimeters   in    diameter,    and    did    not   communicate    with 


47 

the  lateral  ventricle.  The  origin  of  the  cyst  comes  in  ques- 
tion. 

We  are  able  to  do  no  more,  perhaps,  than  enumerate  possi- 
bilities. 

Without  reference  to  the  subject's  history  we  might  propose 
that  this  condition  of  gliotic  cyst  could  be  labeled  anatomically 
as  follows :  — 

1.  Agenesia,  defining  a  condition  in  which  the  original  tissue 
had  never  been  deposited  in  embryonic  life. 

2.  Aplasia,  defining  a  condition  in  which  the  original  elements 
laid  down  in  this  focus  failed  to  develop  for  some  reason. 

3.  Necrosis  of  focal  character,  defining  a  condition  in  which 
the  necrotizing  agent  destroyed  cells  which  had  normally  de- 
veloped.   Under  this  head  might  be  considered  — 

(a)  Infarction  of  embolic  or  thrombotic  origin. 

(&)  Hemorrhage  with  absorption  and  incomplete  repair. 

(c)  Abscess,  tubercle,  gumma  or  other  infective  lesion,  fol- 
lowed by  absorption  of  disease  products  without  adequate  re- 
placement with  scar-tissue  or  gliosis. 

(d)  Echinococcus  disease. 

4.  Tumor  formation  with  cystic  degeneration  (cystic  glioma 
or  gliosis  with  cyst  formation). 

The  history  of  the  subject  fails  to  support  several  of  the 
possibilities  mentioned,  and  indeed  seems  inconsistent  with  a 
number  of  them.  Perhaps  the  earliest  symptoms  were  due  more 
to  heightened  intracranial  pressure  than  to  the  focal  lesion.  The 
greater  emphasis  at  times  of  right  parietal  headache  might  be 
ascribed  to  the  focal  lesion.  In  any  event,  the  results  of  the  focal 
lesion  and  the  results  of  the  consequent  increase  of  intracranial 
pressure  can  hardly  be  separated  clinically  at  this  time. 

The  woman  had  been  perfectly  normal  up  to  the  onset  of  her 
disease  six  years  before  death.  She  had  been  a  capable  trained 
nurse.  Clinically  there  could  be  no  suspicion  of  maldevelopment, 
or  of  any  form  of  bacterial  or  parasitic  infection. 

Disregarding  the  clinical  data  for  the  time  being,  we  are  in  a 
position  to  exclude  the  likelihood  of  most  of  the  possible  condi- 
tions mentioned  above.  The  absence  of  vessel  lesions  and  of 
phagocytic  cells  is  striking.  The  normal  character  of  tissues  a 
few  millimeters  distant  from  the  gliotic  wall  of  the  cyst  is  sug- 
gestive of  an  acquired,  rather  than  of  a  congenital,  lesion. 

We  have  thought  it  worth  while  to  present  the  case  as  a 
phenomenon  to  be  explained.     No   explanation  seems    so   satis- 


48 

factory  as  that  of  glioma  with  cystic  degeneration.  This  diag- 
nosis fails,  however,  to  explain  much,  since  the  significance,  both 
of  glioma  and  of  cystic  degeneration,  remains  unclear.  The  best 
suggestion  we  can  offer  is  that  the  condition  is  analogous  to 
syringomyelia.  Gliotic  cysts  of  the  cerebrum  will  be  understood 
when  syringomyelia  is  understood.  Both  conditions  depend  for 
their  explanation  upon  the  theory  of  neuroglia  changes.  Let  the 
nerve  tissues  of  a  part  of  the  superior  parietal  lobule  in  this  case 
undergo  a  slow  death  like  that  in  the  tissues  of  the  posterior  horn 
of  the  spinal  cord  in  a  case  of  syringomyelia.  Vascular  lesions 
fail  to  ensue.  The  neuroglia  attempts  to  fulfil  the  function 
usually  attributed  to  it,  —  replacement-gliosis.  The  attempt  is  a 
failure,  as  in  the  banal  condition  of  cerebral  infarction,  and  a 
condition  grossly  resembling  a  cyst  of  softening  follows.  Altera- 
tions in  the  amount  of  enclosed  liquid  ensue,  just  as  in  syrin- 
gomyelia, and  effect  alterations  of  symptoms,  complicated,  how- 
ever, to  an  extent  not  possible  in  syringomyelia,  by  heightened 
intracranial  pressure. 

Just  as  in  syringomyelia,  it  is  perhaps  not  possible  to  allege 
that  the  destruction  of  nerve  elements  in  the  area  which  after- 
wards becomes  cystic  is  a  primary  or  direct  destruction  of  nerve 
elements.  Is  it  possible  that  the  gliosis  is  primary  and  not  wholly 
a  replacement-gliosis? 

Further  cases  may  determine  whether  there  is  a  cerebral  disease 
which  proceeds  on  the  lines  of  syringomyelia. 

Southard,  E.  E.  Lesions  of  the  Granule  Layer  of  the  Human 
Cerebellum.  Journal  of  Medical  Research,  Boston,  1907, 
XVI,  99-116. 

Southard,  E.  E.  On  the  Mechanism  of  Gliosis  in  Acquired 
Epilepsy.  American  Journal  of  Insanity^  Baltimore,  1907- 
08,  LXIV,  607-641. 

Summary. 
The  theory  of  epilepsy  expounded  in  the  present  paper  is 
founded  mainly  upon  structural  considerations.  The  histological 
data  have  been  interpreted  largely  from  a  functional  point  of 
view.  The  theory  lays  claim  to  some  originality  in  two  directions, 
in  setting  forth,  namely,  the  properties  of  a  typical  epileptogenic 
focus  in  the  cerebral  cortex,  and  the  nature  of  that  change  in 
cortical   tissue   which   favors   epileptic   discharges.      The   charac- 


49 

teristic  feature  of  a  typical  prime  focus  is  described  as  the  sepa- 
ration of  a  normal  cell-group  from  its  normal  control  by  other 
cell-groups,  and  the  impact  upon  the  receptive  surfaces  of  these 
normal  cells  of  a  steady,  intimate,  abnormal  pressure,  both  seg- 
regation and  compression  effected  by  neuroglia  overgrowth.  That 
feature  of  cortical  tissue  which  , favors  the  spread  of  epileptic 
discharges  is  described  as  due  to  a  simplification  of  cell  arrange- 
ments, arising  in  the  destruction  of  controlling  elements  with 
maintenance  of  motor  elements.  In  the  production  of  both  prime 
focus  and  the  abnormal  tissue  which  permits  uncontrolled  dis- 
charge, the  neuroglia  tissue  plays  a  characteristic  part  —  exerting 
an  active  continued  pressure  in  the  first  instance,  and  readily 
permitting  lateral  discharges  and  the  activation  of  great  groups 
of  motor  cells  in  the  second  instance.  In  the  former  case  we  see 
a  fresh  example  of  the  irritative  property  of  heightened  tension 
—  only  here  exhibited  quite  in  miniature.  In  the  latter  instance 
we  are  dealing  with  conditions  of  still  greater  theoretical  interest, 
approximating,  though  with  diverse  outcome,  the  loss  of  insula- 
tion seen  in  foci  of  disseminated  sclerosis.  The  findings  suggest 
the  widely  different  effects  upon  nervous  tissues  of  active  and  of 
quiescent  gliosis. 

From  a  review  of  pertinent  literature,  it  appears  that  physio- 
logical interest  is  converging  upon  the  field  here  considered. 
Fiber-tract  studies  have  failed  to  cope  with  other  problems  than 
those  of  linear  transmission  along  well-insulated  paths.  Only  in 
the  case  of  multiple  disseminated  sclerosis  and  certain  studies  in 
interstitial  neuritis  have  the  occurrence  and  nature  of  lateral  dis- 
charge from  fiber  to  fiber  and  the  effects  of  intimate  fiber  pres- 
sure been  considered.  And  in  these  instances  it  may  well  be 
proposed  that  a  fresh  abnormal  type  of  synaptic  tissue  has  been 
provided.  Physiological  interest  is  now  leveled  upon  the  synap- 
tic tissues  in  general.  And,  if  a  synapse  is  a  physical  surface  of 
separation  between  neurones,  it  is  serviceable  to  inquire  what  are 
the  conditions  which  can  readily  modify  the  synapse.  The  neu- 
roglia tissue,  formerly  regarded  as  purely  supportive  in  function, 
here  rises  to  a  high  scale  of  importance.  The  present  essay  points 
out  two  effects  of  gliosis  upon  synaptic  tissues,  the  one  an 
active  irritative  one,  the  other  a  passive  effect.  A  review  of  the 
fundamental  views  of  Hughlings  Jackson  serves  to  demonstrate 
the  perfect  generality  of  epileptic  phenomena  at  all  levels,  and 
makes  clear  why  the  writer  sought  knowledge  about  epilepsy  in 
organic  cases.     If  the  writer  advances  a  case  in  which  the  prime 


50 

epileptogenic  focus  consists  in  an  active  gliosis  within  a  space  of 
1  cubic  centimeter  in  the  cornu  ammonis,  he  cannot  be  charged 
with  holding  that  all  cases  of  epilepsy  are  so  brought  about.  He 
describes  what  he  regards  as  a  typical  prime  focus.  He  conceives 
fundamentally  that  similarly  forcible  and  lasting  stimulation  of 
a  receptive  surface,  standing  in  important  relations  to  the  motor 
system,  might  produce  epileptic  convulsions  just  as  effectively  as 
the  gliosis  he  describes.  In  this  sense  complex  emotions  or  intes- 
tinal worms  might  conceivably  stand  in  as  effective  a  relation  to 
the  nervous  system  as  the  intimate  pressure  of  early  gliosis  upon 
the  expansions  of  elements  whose  currents  eventually  play  upon 
the  muscular  system. 

"Wholly  distinct  from  these  considerations  about  epileptogenic 
foci  are  those  points  which  are  developed  concerning  tissues 
facilitating  discharge.  A  review  of  various  authors  discovered 
much  difference  of  opinion  and  considerable  interpretation  of 
phenomena  as  secondary.  The  phenomenon  of  gliosis  has  not 
escaped  numerous  observers,  among  them  the  very  observers  that 
have  emphasized  the  alterations  of  the  second  cortical  layer  as 
important  in  epilepsy.  But  this  gliosis  has  been  regarded  as 
secondary,  and  our  attention  has  been  diverted  rather  to  certain 
cell  and  nuclear  characters  which  are  looked  upon  as  specific. 
The  writer  has  been  tempted  to  regard  these  nerve-cell  changes 
as  vegetative,  and  at  any  rate  as  not  further  analyzable,.but  to 
accept  them  as  examples  of  a  lesion  which  will  interfere  with 
normal  control  of  muscular  elements.  The  cases  presented  here 
go  far  to  prove  that  the  nerve  cells  of  the  outer  layers  are  the 
first  to  disappear  in  cases  of  atrophy,  and  even  along  the  edges  of 
ischemic  areas.  The  tendency  to  the  formation  of  tissue  favor- 
able to  epileptic  discharge  is,  according  to  this  view,  a  somewhat 
general  tendency  in  cerebral  tissue  so  long  as  the  destroying 
forces  stop  short  of  the  motor  elements  and  permit  any  com- 
munication, however  slight,  between  the  motor  elements  and  the 
receptive  side  of  the  body.  A  reduction  or  simplification  of  the 
system  through  destruction  of  the  smaller  elements  of  the  cere- 
bral cortex  procures  new  reflex  arcs  with  fresh  surfaces  of  separa- 
tion which  are  perhaps  even  simpler  and  more  automatic  than 
the  spinal  arcs  and  synapses.  The  peculiar  features  of  the  epilep- 
tic discharge  depend  upon  the  inertia  of  currents  travelling  in 
simplified  arcs,  and  upon  the  lack  of  energy-absorbents  en  route. 
The  cerebral  arcs  normally  escape  automatism  through  a  multi- 
tude of  synaptic  connections;   under  epileptic  conditions  the  cere- 


51 

bral  mechanism  approaches  in  fatality  the  spinal  mechanism. 
Under  this  conception  epilepsy  and  phenomena  like  clonus  are 
readily  perceived  to  belong  to  a  single  logical  group. 

The  phenomenon  of  epilepsy,  in  short,  requires  the  intactness 
and  even  the  normality  of  some  well-defined  route  from  stimulus 
to  muscles.  If  we  conceive  the  stadia  of  this  route  set  end  to 
end,  with  the  cerebral  synaptic  tissue  in  the  middle,  we  perceive 
that  toward  the  two  ends  of  the  linear  series  it  becomes  increas- 
ingly difficult  to  provide  conditions  which  will  produce  general- 
ized and  spreading  convulsions.  Destruction  of  elements  at  any 
point  in  the  route  should  at  first  sight  exclude  the  production  of 
epilepsy.  And  so,  in  most  cases,  the  destruction  of  the  efferent 
paths  will  exclude  epilepsy.  In  the  afferent  paths,  however,  the 
very  process  of  destruction  often  constructs  new  and  potent  sur- 
faces of  stimulation  which  act  as  epileptogenic  foci;  and,  in  the 
cerebral  synaptic  tissue,  the  strata  are  so  constructed  that  the 
loss  of  smaller,  central,  modifying  and  inhibitory  elements  is 
effected  prior  to  the  loss  of  the  major  elements  which  are  es- 
sential to  the  intactness  of  the  great  route.  And  these  major 
efferent  elements  can  themselves  be  subject  from  time  to  time  to 
stimulation  afforded  by  the  contractile  energies  of  growing 
neuroglia.  Epileptogenic  stimuli  are  applied  in  all  cases  to  those 
elements  having  a  forward  direction,  so  that  the  reaction  is  in 
most  cases,  if  not  necessarily,  a  sensorimotor  reaction  in  Hugh- 
lings  Jackson's  sense. 

What  are  the  applications  of  this  theory  to  the  phenomena  of 
idiopathic  epilepsy?  In  certain  cases  of  idiopathic  epilepsy  there 
seems  to  be  grave- doubt  whether  any  adequate  epileptogenic  foci  can 
be  discovered.  There  is  more  hope  that  tissues  faoorable  to  epileptic 
discharge  shall  be  discovered,  if  the  proper  methods  are  employed. 

We  can  see  some  reason  for  the  absence  of  effective  foci  in 
hereditary  cases,  particularly  if  we  bear  in  mind  the  epileptic 
offspring  of  Brown-Sequard's  injured  guinea  pigs.  With  the 
onset  of  topographic  and  stratigraphic  knowledge  of  the  cerebral 
cortex  we  shall  approach  more  nearly  to  a  definition  of  tissues 
suitable  for  the  propagation  of  epileptic  discharges.  So  far  it 
seems  that  such  synaptic  tissues  are  characterized  by  abnormally 
simplified  arcs  whose  impulses  are  the  more  automatic  through 
the  lack  of  countercurrents  from  surrounding  cells.  Whether 
we  are  to  look  in  inherited  serum  properties  for  the  production 
of  such  conditions,  the  future  will  decide.  Destroying  agents  of 
moderate  power  tend  to  alter  tissues  in  this  direction. 


52 

Gay,  F.  P.,  and  Southard,  E.  E.  On  Serum  Anaphylaxis  in  the 
Guinea  Pig.  Journal  of  Medical  Research,  Boston,  1907, 
XVI,  143-180.     (New  Series,  Vol.  XL) 

Conclusions. 

1.  The  well-known  susceptibility  to  intoxication  by  horse 
serum,  which  is  demonstrable  in  guinea  pigs  previously  injected 
with  horse  serum,  is  due  to  the  non-neutralization  and  non- 
elimination  by  the  animal  body  of  a  factor  in  the  serum,  for 
which  we  suggest  the  name  anaphylactin.  The  intoxication 
caused  by  the  second  injection  depends  upon  factors  of  the  serum 
other  than  anaphylactin.  These  factors  correspond  to  con- 
stituents of  the  serum  eliminable  by  the  animal  body.  The 
reaction  of  intoxication  would  seem  to  be  a  cellular  one,  de- 
pendent upon  a  heightened  power  of  assimilation  on  the  part  of 
cells  which  have  been  subjected  to  the  anaphylactic  substance 
over  a  definite  period  of  incubation. 

2.  The  tissues  of  guinea  pigs,  examined  during  the  anaphylac- 
tic phase,  show  no  characteristic  lesions.  Striking  multiple 
hemorrhages,  for  some  reason  hitherto  undescribed,  accompany 
the  toxic  phase.  The  hemorrhages  are  more  frequent  in  the 
stomach,  cecum,  lungs  and  heart  than  elsewhere. 

Microscopic  study  demonstrates  that  the  hemorrhages  are 
largely  associated  with  widespread  fatty  degeneration  of  the 
capillary  endothelium.  The  heart  muscle,  the  voluntary  muscle, 
the  peripheral  nerves  and  the  gastric  epithelium  show  striking 
focal  fatty  changes  which  are  independent  of  the  vascular  lesions. 

The  task  of  the  anaphylactin  is  apparently  so  to  prepare 
various  cell  structures  that  their  contained  fat  is  made  to  flow 
rapidly  together  upon  exposure  to  the  toxic  agent.  The  rapidity 
of  this  degeneration  is  striking,  though  it  presents  histologically 
the  features  of  so-called  "chronic"  degeneration. 

Southard,  E.  E.  and  Hodskins,  M.  B.  Note  on  Cell  Findings 
in  Soft  Brains.  American  Journal  of  Insanity,  Baltimore, 
1907-08,  LXIV,  305-310. 

Remarks. 
The  anatomist  is  prone  to  neglect  the  general  feel  of  the  brain 
and  cord  at  autopsy.     He  is  familiar  enough  with  focal  altera- 
tions of  consistence;    thus,  with  foci  of  induration   (scars,  focal 


53 

glioses)  and  with  foci  of  subnormal  consistence  (focal  encephalo- 
malacia,  focal  encephalitis).  A  state  of  general  induration  is 
recognized  as  due  to  diffuse  fibrillar  gliosis.  General  reduction 
of  consistence  is  least  easy  to  interpret. 

The  plastic  softness  and  swelling  of  edematous  brains  may  be 
told  from  the  dimuence  of  brains  as  autolyzed  post-mortem.  We 
have  here  noted  a  condition  of  general  encephalomalacia  which 
we  take  to  be  of  ante-mortem  origin,  though  doubtless  it  is 
speedily  emphasized  by  post-mortem  changes. 

The  soft  brains  and  soft  cords  of  this  group  are  not  produced 
by  vascular  lesions,  and,  unlike  edematous  organs,  show  no  essen- 
tial increase  of  volume  or  weight.  This  type  of  general  encephalo- 
malacia (myelomalacia)  seems  not  unlike  the  state  of  the  brain 
and  cord  after  post-mortem  autolysis,  and  is  possibly  due  to  a 
similar  process. 

Although  the  process  has  the  appearance  of  a  general  histo- 
lysis, yet  histological  study  shows  that  the  lysis  is  essentially 
differential  (diffuse  axonal  reactions  in  nerve  cells  and  still  more 
diffuse  Marchi  degenerations).  Where,  as  in  the  illustrative  case, 
a  focal  induration  also  occurs,  the  histolysis  is  readily  seen  to  be 
differential  because  the  nerve  cells  and  fibers  which  still  live  in 
the  sclerotic  focus  are  subject  to  the  same  cytolyses  (axonolyses) 
as  are  the  cells  and  fibers  of  the  brain  at  large.  Wrhat  the  lytic 
agent  is  remains  obscure. 

General  encephalomalacia  (myelomalacia,  neuromalacia?)  is 
clinically  related  with  a  late,  terminal,  or  agonal  exhaustion,  and 
is  sometimes  seen  following  epilepsy  as  well  as  in  other  conditions. 


1908. 

Bullard,  W.  N.,  and  Southard,  E.  E.  A  Case  of  Syringal 
Hemorrhage  complicated  by  Meningitis.  (Abstract.)  Jour- 
nal of  Nervous  and  Mental  Disease,  New  York,  1908, 
XXXV,  37. 

Remarks. 
The  readers  interpreted  the  data  of  this  case  as  illustrating  the 
following  series  of  events:  (1)  gliosis  with  cavity  formation  in 
the  spinal  cord;  (2)  hemorrhage  into  cavity  with  defects  tanta- 
mount to  those  of  transverse  myelitis;  (3)  extensive  decubitus 
with  erosion  of  bone  and  exposure  of  spinal  canal;  (4)  ascending 
meningitis. 


54 

Mitchell,  H.  W.,  and  Southard,  E.  E.  Melancholia  with  De- 
lusions of  Negation:  Three  Cases  with  Autopsy.  Journal 
of  Nervous  and  Mental  Disease,  New  York,  1908,  XXXV, 
300-314. 

General  Summary  and  Remarks. 

The  disease  group  melancholia  has  a  somewhat  precarious 
footing  in  present-day  psychiatry.  The  purest  cases  appear  to 
occur  in  or  about  the  climacteric  era.  The  practical  alienist  is 
always  reluctant  to  place  a  case  in  the  group  melancholia  lest  it 
shortly  transpire  that  the  case  should  rather  have  been  counted 
senile  or  arteriosclerotic,  or,  in  some  other  way,  frankly  organic. 
Moreover,  it  frequently  appears  that  error  may  creep  in  the 
opposite  direction,  and  the  patient,  alleged  to  have  melancholia, 
turn  out  to  be  actually  a  victim  of  some  constitutional  defect  or 
of  some  acute  psychosis. 

We  have  found  difficulty  in  resolving  our  ideas  about  the  dis- 
ease group  melancholia,  and  were  for  a  time  inclined  to  believe 
that  any  given  case  could  perhaps  be  transmuted,  as  a  matter 
of  diagnosis,  into  some  other  group. 

As  a  beginning  in  this  group  we  have  here  introduced  three 
cases  which,  whether  they  fit  any  acknowledged  grouping  or  not, 
appear  to  have  certain  features  in  common  as  well  as  certain 
instructive  differences.  The  psychological  color  and,  to  some 
extent,  the  course  of  these  cases  recall  some  features  of  Cotard's 
syndrome. 

In  every  case  there  were  a  few  established  instances  of  in- 
sanity in  the  direct  line  on  one  or  other  side.  The  hereditary 
features,  interesting  in  each  case,  appear  to  have  little  in  common 
except  the  terminal  continuous  depressions  in  the  mothers  of 
two  patients  (Cases  II  and  III). 

The  lives  of  the  three  patients  showed  little  which  can  be 
regarded  as  underlying  their  ultimate  conditions.  Case  I  used 
no  alcohol,  Case  II  drank  beer  with  meals,  Case  III  used  alcohol 
moderately.     Venereal  history  practically  negative  in  all  cases. 

Occupations:    clerk,  I;    mason,  II;    shoemaker,  III. 

Previous  diseases:  lumbago,  I;  pneumonia  seven  years  before 
commitment,  II;  scarlet  fever  and  purulent  otitis  media,  set.  3, 
and  typhoid  fever  and  la  grippe  with  delirium,  set.  61,  III. 

Ages  at  onset:  48,  I;    (69)  75,  II;   65,  III. 

Durations:  8  months,  I;    (8  years)  2  weeks,  II;  24  weeks,  III. 

Onset:  gradual,  I,  III;   sudden,  II. 


55 

Assignable  causes:  financial  worry,  I;  senility  and  domestic 
worry,  II;   nothing,  set.  65,  III. 

Physical  conditions:  arteriosclerosis  in  all  cases;  Case  III 
showed  emaciation,  nephritis,  cystitis,  increase  of  reflexes. 

Mental  states:  ideas  of  negation  in  all  cases,  developing  in 
Case  I  after  slowly  increasing  depression  and  agitation  with  delu- 
sions about  self  and  family  and  questionable  hallucinations;  in 
Case  II,  after  gradual  senile  failure,  as  sudden  deep  depression 
with  agitation,  delusions  of  ruin  of  self  and  family,  and  suicidal 
attempt;  and  in  Case  III,  after  slowly  developing  hypochondri- 
acal depression. 

The  feelings  of  unreality  and  ideas  of  negation  presented  a 
certain  variety  in  the  three  cases.  Case  I  showed  an  alteration 
of  personality,  uttered  frequently  in  such  phrases  as  "I'm  all 
gone.  I'm  dead  to  the  world.  I'm  not  G.  E.  H.  I've  made  my- 
self as  Gibbs.  I've  been  here  as  G.  E.  H."  Case  II  showed  a 
feeling  of  unreality,  both  as  regards  the  outer  world  ("sunlight 
not  real,  sky  not  blue,  people  not  real  human  beings")  and  as 
regards  himself  ("I  can't  move.  I  can't  die").  Case  III  showed 
an  alteration  of  point  of  view  as  to  the  outer  world  ("You're  all 
great  big  men,  and  so  strong;  you  must  weigh  over  400  pounds") 
and  nihilistic  ideas  ("I  am  so  small  you  can't  see  me.  I've  got 
no  brains,  and  I  can't  talk.  I've  got  no  heart,  and  no  stomach, 
and  I  can't  swallow.  I  wouldn't  burn  if  you  threw  me  in  the 
burning  furnace"). 

The  anatomical  side  of  these  cases  presents  several  common 
aspects,  but  little  which  promises  to  explain  the  disease.  Arterio- 
sclerosis, when  confined  to  the  large  branches  of  the  circle  of 
Willis,  can  scarcely  be  invoked  as  underlying  symptoms  of  such 
specialized  character  as  those  under  consideration. 

Just  as  the  patients  showed  strikingly  little  in  alterations  of 
reflexes  (increase  in  Case  III),  so  the  brains  showed  strikingly 
little  in  the  shape  of  gross  or  focal  ilterations  (small  old  cyst  of 
softening  in  Case  II  and  mild  chronic  exudative  process  in  Case 
III). 

Moreover,  the  brains  gave  little  evidence  of  general  or  focal 
atrophy.  No  striking  alterations  in  cortical  topography  and 
arrangement  of  layers  could  be  detected  on  microscopic  examina- 
tion. Pigment-bearing  cells  in  perivascular  spaces  were  con- 
stantly found;  and,  in  default  of  any  suspicious  localization  of 
these,  we  must  attribute  them  rather  to  the  results  of  advancing 
years  than  to  a  special  factor. 


56 

Neuroglia  cell  pigmentation  was  also  quite  constantly  found; 
but  this  was  not  so  universal  in  distribution  as  was  the  case  with 
the  perivascular  cell  pigmentation.  Common  to  all  three  cases 
was  a  neuroglia  cell  pigmentation  in  the  intermediate  layers  of 
the  areas  of  cortex  examined.  The  relation  of  the  neuroglia 
cell  pigmentation  to  cortical  activity  could  not  be  made  out. 
Satellite-cell  pigmentation  was  not  constant. 

Nerve  cell  pigmentation  was  constantly  found  in  the  elements 
of  moderate  size  in  all  parts  of  the  cortex  examined.  This  pig- 
mentation was  strikingly  brought  out  by  the  use  of  iron  hema- 
toxylin. The  pigmentation  in  question  has  a  somewhat  charac- 
teristic locus  in  the  affected  cells,  fails  to  destroy  their  contours, 
and  lies  apparently  in  interstices  in  the  cells.  This  interstitial 
nerve  cell  pigmentation,  as  brought  out  by  iron  hematoxylin,  is 
to  be  sharply  distinguished  from  the  familiar  yellow  sack  pig- 
mentation of  the  major  elements. 

Pending  the  increase  of  knowledge  concerning  the  pigments 
and  fat-like  deposits  in  general,  we  can  at  least  investigate  their 
occurrence  topographically.  It  seems  to  us  that  however  frag- 
mentary the  present  findings  are,  and  however  far  we  may  be 
from  bringing  such  findings  into  relation  with  disorders  of  ap- 
perception, we  have  at  least  a  promising  field  for  investigating 
the  conditions  of  what  seems  to  be  a  truly  cortical  disorder.  We 
are  at  present  at  work  upon  accessible  cases  of  melancholia. 

Gay,  F.  P.,  and  Southard,  E.  E.  Further  Studies  in  Anaphy- 
laxis: I.  On  the  Mechanism  of  Serum  Anaphylaxis  and  In- 
toxication in  the  Guinea  Pig.  Journal  of  Medical  Research, 
Boston,  1908,  XVIII,  407-431.     (New  series,  Vol.  XIII.) 

Gay,  F.  P.,  and  Southard,  E.  E.  Further  Studies  in  Anaphy- 
laxis: II.  On  Recurrent  Anaphylaxis  and  Repeated  In- 
toxication in  Guinea  Pigs  by  Means  of  Horse  Serum.  Jour- 
nal of  Medical  Research,  Boston,  1908,  XIX,  1-4.  (New 
series,  Vol.  XIV.) 

Gay,  F.  P.,  and  Southard,  E.  E.  Further  Studies  in  Anaphy- 
laxis: III.  The  Relative  Specificity  of  Anaphylaxis.  Pro- 
ceedings, Society  of  Experimental  Biology  and  Medicine, 
New  York  (Conclusions  only),  1907-08,  V,  83.  Also  in 
Journal  of  Medical  Research,  Boston,  1908,  XIX,  5-15. 
(New  series,  Vol.  XIV.) 


57 


Conclusions. 

The  anaphylaxis  in  guinea  pigs  caused  by  the  previous  in- 
jection of  any  one  of  the  protein  substances  —  horse  serum, 
egg  white  or  milk  —  is  only  relatively  specific.  The  maximum 
reaction  on  second  injection  is  always  obtained  when  the  sub- 
stance which  has  sensitized  is  used,  but  in  certain  combinations 
intoxication  can  be  produced  by  the  other  two  substances.  This 
intoxication  by  a  heterologous  proteid  is  "partial,"  and  does  not 
occur  if  the  "complete"  intoxication  produced  by  the  homologous 
proteid  has  been  effected.  When  partial  intoxication  has  been 
produced  by  one  or  both  of  the  heterologous  substances,  com- 
plete intoxication  may  still  be  effected  by  the  homologous  sub- 
stance. The  intensity  of  an  homologous'  intoxication,  after 
anaphylaxis  by  a  single  substance,  would  seem  to  depend  some- 
what on  the  substance  used,  the  order  of  toxicity  ranging,  egg 
white,  serum,  and  last  of  all  milk.  After  combined  anaphy- 
laxis, produced  by  initial  injection  of  all  three  substances,  the 
first  intoxication,  allowing  of  course  a  proper  incubation  period, 
may  be  produced  by  any  one  of  the  substances  in  question. 
When  intoxications  are  effected  with  each  substance  in  turn,  the 
serial  set  of  symptoms  varies  according  to  the  order  in  which 
the  substances  are  injected  on  the  subsequent  days.  When  in- 
jected as  the  second  or  third  of  the  series,  egg  white  alone  pro- 
duces maximal  symptoms  at  all  times.  Horse  serum  is  diminished 
in  toxicity  if  used  after  either  egg  or  milk,  and  has  lost  markedly 
if  used  after  intoxication  with  both  substances.  Milk  is  very 
slightly  toxic  if  given  second  in  order,  and  absolutely  non-toxic  if 
given  third.  This  would  compare  with  the  actual  toxic  power  of 
each  substance  as  noted  after  homologous  sensitization. 

The  mixed  anaphylaxis,  moreover,  is  only  relatively  specific, 
since  egg  and  horse  serum  will  completely  pre-empt  the  possibil- 
ity of  intoxication  by  milk  if  this  substance  is  given  last. 

Gay,  F.  P.,  and  Southard,  E.  E.  Further  Studies  in  Anaphy- 
laxis: IV.  The  Localization  of  Cell  and  Tissue  Anaphylaxis 
in  the  Guinea  Pig,  with  Observations  on  the  Cause  of  Death 
in  Serum  Intoxication.  Journal  of  Medical  Research,  .Bos- 
ton, 1908,  XIX,  17-35.     (New  series,  Vol.  XIV.) 

CoxcLrsioxs. 
The  results  of  this  work  are  in  part  confirmatory  of  our  previ- 
ous results,  and  consist  in  part  of  novel  data. 


58 

Eighty-five  per  cent  of  guinea  pigs  which,  after  sensitization 
with  horse  serum  and  intoxication  by  a  second  dose  of  horse 
serum,  die  in  the  critical  phase,  or  are  killed  within  twenty -four 
hours  of  the  second  injection,  exhibit  macroscopic  hemorrhages 
in  one  or  more  organs.  The  stomach  leads  the  other  organs  in 
frequency  of  involvement  (58  per  cent);  the  lungs  stand  next 
(40  per  cent).  Three  unusual  localizations  of  hemorrhage,  not 
noted  in  our  previous  paper,  are  brain,  spinal  cord,  perito- 
neum. 

The  cause  of  death,  when  it  occurs,  is  respiratory.  Respira- 
tion ceases  in  the  inspiratory  phase,  and  shows  itself  anatomi- 
cally and  histologically  as  emphysema.  Death  does  not  occur, 
as  a  result  of  this  disease,  except  in  a  critical  phase,  which 
occupies  at  most  one  hour. 

The  most  striking  functional  feature  of  the  critical  phase,  after 
the  second  or  toxic  injection  of  horse  serum,  is  severe  diaphrag- 
matic spasm.  The  spasms  are  often  accompanied  by  similar 
shock-like  spasms  of  the  accessory  inspiratory  muscles  and  of 
other  trunk  and  limb  muscles. 

The  most  rapid  deaths  are  produced  by  intracarotid,  intra- 
jugular,  post-orbital,  and  paraneuraxial  injections.  The  occur- 
rence and  rapidity  of  death  in  the  critical  phase,  as  well  as  the 
severity  of  respiratory  symptoms  throughout  the  toxic  phase, 
appear  to  vary  with  the  nearness  of  the  toxic  injections  to  the 
respiratory  central  apparatus. 

A  new  line  of  research  is  opened  up  by  the  paraneuraxial  in- 
jections of  horse  serum  in  sensitized  guinea  pigs.  These  seem  to 
prove  that  differential  irritative  and  paralytic  reactions  can  be 
secured  by  small  localized  injections  of  horse  serum  adjacent  to 
various  parts  of  the  sensitized  central  nervous  axis. 

Severe  respiratory  symptoms  can  be  produced  in  sensitized 
(but  not  in  normal)  guinea  pigs  by  local  applications  of  horse 
serum  (not  by  salt  solution)  to  the  exposed  vagus.  This  is  inter- 
preted to  signify  a  conveyance  of  impulses  over  at  least  three 
neurones  to  the  diaphragm,  that  is,  to  the  medulla,  thence  to  the 
phrenic  center,  and  thence  to  the  diaphragm.  We  have  not  pro- 
duced death  by  these  vagal  applications  of  horse  serum. 

To  explain  these  respiratory  symptoms,  we  offer  an  hypothe- 
sis of  local  tissue  anaphylaxis  expressed  in  a  relatively  specific 
sensitization  of  the  respiratory  centers.  We  regard  as  unfounded 
those  hypotheses  which  consider  the  respiratory  (and  other) 
centers  and  tissues  as  unaltered  in  the  anaphylactic  or  sensitizing 


59 

phase,  and  which  allege  the  manufacture  of  antibodies  in  the 
blood  serum  which  later  unite  with  the  second  dose  of  horse 
serum  to  form  new  specific  respiratory  toxines.  We  regard  this 
change  induced  in  the  respiratory  centers  as  of  a  physical  rather 
than  a  chemical  nature,  so  far  as  this  distinction  is  of  importance 
in  this  connection. 

Neither  hemorrhage  nor  respiratory  death  is  an  indispensable 
feature  of  this  disease.  Some  guinea  pigs  show  no  hemorrhages. 
Some  show  slight  symptoms.  The  hemorrhages  do  not  vary  in 
frequency  or  extent  with  the  severity  of  the  symptoms  in  all 
cases. 

But  all  guinea  pigs  so  far  examined  in  the  toxic  phase  do  show 
focal  fatty  changes  in  many  tissues  of  several  genetic  types. 
These  changes  are,  in  many  regions,  of  an  extremely  focal  char- 
acter, involving  often  a  single  muscle  fiber,  nerve  fiber,  or  other 
cell,  as  the  case  may  be.  The  toxic  phase  is  characterized  by 
focal  cytolyses  of  wide  distribution.  Except  in  areas  of  hemor- 
rhage (where  local  mechanical  destruction  complicates  findings), 
and  in  certain  diffuse  fatty  changes  in  the  gastric  epithelium 
(where  the  local  action  of  the  gastric  juice  may  come  in  play), 
groups  of  contiguous  cells  are  not  characteristically  affected  by 
fatty  change  —  focal  histolysis  is  not  the  rule. 

And,  if  focal  cytolysis  (rather  than  focal  histolysis)  is  the  rule 
in  the  toxic  phase,  then  it  appears  that  the  work  of  the  anaphy- 
lactic phase  is  to  sensitize  cells  in  a  variable  degree  (rather 
than  to  sensitize  several  contiguous  or  regionary  cells  in  a  like 
degree). 

Southard,  E.  E.  and  Richards,  E.  T.  F.  Typhoid  Meningitis: 
Cultivation  of  Bacillus  Typhosus  from  Meninges  and  Mes- 
enteric Lymph  Node  in  a  Case  of  General  Paresis,  with  a 
Note  on  Experimental  Typhoid  Meningitis  in  the  Guinea 
Pig.  Journal  of  Medical  Research,  Boston,  1908,  XIX, 
513-531. 

Conclusions. 

The  points  of  the  paper  are  as  follows:  — 

1.  A  classical  case  of  taboparesis,  with  previous  history  of 
syphilis,  but  without  history  of  typhoid  fever,  succumbs  after  a 
week's  acute  illness  to  broncho-pneumonia  and  to  purulent 
cerebrospinal  meningitis. 


60 

2.  A  typical  strain  of  Bacillus  typhosus  was  isolated  in  pure 
culture  from  a  swollen  mesenteric  lymph  node  and  from  the 
meningeal  pus.  The  blood  failed  to  yield  Bacillus  typhosus. 
There  were  no  typhoidal  lesions  in  the  intestines. 

3.  The  meningeal  exudation  contained  polynuclear  leucocytes 
in  great  numbers.  This  finding,  in  connection  with  the  older 
findings  of  Ohlmacher,  W.  G.  MacCallum,  and  Henry  and 
Rosenberger,  leads  to  the  hypothesis  that  Bacillus  typhosus 
within  the  meninges  may  exert  a  directly  pyogenic  action. 
Should  this  hypothesis  be  upheld,  the  direct  action  of  the  bacillus 
stands  in  sharp  contrast  to  the  proliferative  effects  of  the  typhoid 
toxine  described  by  Mallory  in  the  intestine,  lymph  nodes  and 
elsewhere  in  the  viscera.  The  indications  are,  therefore,  that 
Bacillus  typhosus  may  have  two  separate  effects,  the  one  pro- 
duced by  a  diffusible  toxine  (Mallory)  characteristically  in  the 
intestinal  tract,  and  the  other  produced  in  the  meninges  either 
by  direct  local  action  of  the  bacilli  or  through  an  endotoxine, 
due  to  destruction  of  the  bacilli. 

4.  In  confirmation  of  the  results  of  Tictine,  Bacillus  typhosus 
was  experimentally  found  to  inflame  the  meninges  of  guinea  pigs. 
In  accordance  with  the  hypothesis  stated  above,  guinea  pig  brains 
proved  to  show  an  exudation  containing  many  polynuclear 
leucocytes.  Mononuclear  elements  arrive  by  the  seventh  day 
after  inoculation. 

5.  Research  is  desirable  to  determine  whether  the  local  action 
of  Bacillus  typhosus  in  the  meninges  is,  or  is  not,  of  endotoxic 
type. 

Southard,  E.  E.,  and  Ayer,  J.  B.,  Jr.  Dementia  Prsecox,  Par- 
anoid, associated  with  Bronchiectatic  Lung  Disease  and 
terminated  by  Brain  Abscesses  (Micrococcus  Catarrhalis). 
(From  the  Laboratory  of  the  Danvers  Insane  Hospital.) 
Boston  Medical  and  Surgical  Journal,  1908,  CLIX,  890-895. 

Discussion. 
We  have  presented  the  case  of  an  American  youth  of  average 
capacity,  a  chair  maker  for  some  six  years,  who  became  insane 
(depressed,  paranoid,  suicidal,  later  at  times  katatonic)  after 
facial  disfigurement  in  a  Fourth  of  July  accident  at  the  age  of 
twenty-five.  We  were  tempted  to  a  more  particular  study  of  this 
case  because  of  the  clear-cut  features  of  an  autopsy  five  years 
after  onset  (chronic  and  acute  lung  disease  with  abscesses,  mul- 


61 

tiple  abscesses  of  other  organs,  including  the  brain),  which 
seemed  to  point  to  bronchiectases  and  lung  disease  of  ancient 
date. 

The  clinical  history  and  the  autopsy  findings  are  so  far  con- 
sistent that  a  "psychogenic"  origin  for  this  case  of  (possibly) 
dementia  prsecox  can  be  safely  discounted.  It  seems  safe  to 
conclude  that  the  lung  disease  was  already  in  process  of  pro- 
duction in  the  six  months  subsequent  to  the  episode  of  facial 
disfigurement.  It  is  possible  that  this  disease  antedated  the 
facial  injury,  and  that  masses  of  bacteria  in  dilated  bronchi  had 
begun  to  affect  the  patient  long  before  frank  pulmonary  signs 
set  in. 

However  this  may  be,  the  lung  disease,  whose  progress  was 
carefully  followed  on  account  of  its  clinical  resemblance  to  pul- 
monary tuberculosis,  had  a  peculiar  effect  upon  the  course  of 
the  mental  symptoms.  Both  lung  disease  and  mental  disease 
came  in  attacks,  but  these  attacks  did  not  coincide  in  time. 

The  lung  disease  would  affect  in  each  attack  a  fresh  area,  and 
was  characterized  by  exhaustion,  bloody  and  purulent  expectora- 
tion (no  tubercle  bacilli)  and  high  fever. 

During  the  toxemic  phases  of  the  lung  disease  the  patient  was 
quiet,  but  would  yield  depressive  delusions  on  questioning.  Just 
as  earlier  the  patient  had  been  depressed  ostensibly  on  account 
of  his  disfigurement,  so  throughout  his  disease  he  tended  to 
delusions  concerning  his  somatic  condition.  ("This  is  leprosy  I 
am  spitting  up.")  But  his  delusions  were  at  all  times  of  wider 
range  than  his  bodily  disease  ("given  up  by  God,"  "world  is 
degenerating,"  "murdering  the  whole  world"),  and  were  some- 
times of  extreme  metaphysical  ingenuity  ("passed  both  ends  of 
the  world  and  got  behind  everybody"). 

After  some  years  the  paranoid  picture  had  become  emphasized 
by  mild  and  episodic  katatonic  features  (wild  beast  simulations, 
mannerisms  and  peculiar  contortions). 

It  is,  of  course,  possible  that  the  lung  disease  and  the  mental 
disease  are  merely  interpenetrating  entities  in  this  case.  The 
autopsy  showed  that  the  brain,  in  common  with  the  kidneys  and 
the  spleen  and  other  structures,  had  undergone  abscess-formation. 
There  is,  however,  no  evidence  that  the  brain  abscesses  were  of 
long  standing,  and,  though  the  fatal  issue  was  pyemic,  it  is 
probable  that  previous  attacks  had  been  merely  toxemic,  or,  at 
most,  mildly  septicemic.  The  microorganism  engaged  in  the 
abscess-formation  is  not  in  all  respects  well  defined,  but  seems  to 


62 

belong  to  the  micrococcus  catarrhalis  group.  There  is  no  con- 
vincing evidence  that  this  organism  was  in  any  way  responsible 
for  the  clinical  features  of  the  disease  as  a  whole,  but  it  seems 
not  easy  to  exclude,  in  a  more  general  way,  the  presumably 
highly  toxic  masses  of  bacteria  and  detritus  in  the  pulmonary 
tissues  from  the  field  of  factors  in  the  mental  disease. 

Just  as  it  has  long  been  suspected  by  some  workers  that  there 
is  a  somewhat  close  relation  between  lung  disease  and  brain 
disease  (and,  in  particular,  between  bronchiectases  and  brain 
abscesses),  so  there  may  possibly  obtain  a  more  delicate  and 
elusive  connection  between  toxic  lung  conditions  and  brain 
conditions.  It  would  be  of  extreme  value  could  we  learn  more 
precisely  the  paths  taken  by  bacteria  and  toxins  from  the  lungs 
to  the  central  nervous  axis. 

Southard,  E.  E.,  and  Rickshek,  C.  A  Complicated  Case  of 
Brain  Tumor.  American  Journal  of  Insanity,  1908,  LXIV, 
695-702. 

Clinical  Summary. 

It  is  extremely  difficult  to  ascribe  the  various  symptoms  to 
definite  lesions.  The  pontine  lesions  are  of  such  a  degree  that 
they  might  easily  modify  any  symptom  which  could  ordinarily 
be  ascribed  to  the  tumor  or  the  meningitis. 

A  tumor  in  the  frontal  region  rarely,  if  ever,  gives  definite 
localizing  symptoms.  In  this  case  the  apathy  and  indifference  to 
her  surroundings  and  also  the  early  headache  may  be  due  to  it. 
Its  position  near  Broca's  convolution  suggests  some  connection 
with  the  speech  defect,  but  it  is  more  probable  that  the  lesions  in 
the  pons  have  more  to  do  with  it. 

The  ptosis  may  be  accounted  for  by  the  extension  from  the 
Gasserian  ganglion,  but  it  seems  very  probable  that  there  may 
have  been  a  nuclear  lesion.  The  visual  hallucinations  may  be 
accounted  for  by  the  meningitis  and  the  dulling  of  consciousness 
following  it  and  the  tumor. 

The  lesions  in  the  pyramidal  tract  explain  the  Babinski  reflex, 
but  there  hardly  seems  to  be  enough  difference  in  the  two  tract 
lesions  to  explain  why  it  should  exist  on  one  side  and  not  on  the 
other.  There  was  probably  some  focal  lesion  in  the  cervical  cord 
which  interfered  with  the  reflex  arc  of  the  left  arm  and  slightly 
with  that  of  the  right  which  could  explain  the  arm  reflexes. 

The  paralysis  of  the  left  side  was  due  directly  to  the  destruc- 
tion of  the  Betz  cells,  and  this  destruction  can  be  accounted  for 


63 

by  toxic  influences  from  the  meninges  or  by  pressure  from  the 
tumor,  but  one  would  be  inclined  to  give  more  to  the  toxic 
hypothesis.       , 

The  case  offers  nothing  new  so  far  as  localization  is  concerned, 
but  it  does  call  attention  to  the  vast  changes  which  may  be 
caused  by  arteriosclerosis,  and  also  to  the  meningeal  conse- 
quences of  a  chronic  otitis  media.  In  a  large  number  of  the 
cases  which  have  come  to  autopsy  in  this  institution  in  the  last 
six  months  pus  has  been  found  in  the  middle  ear.  There  is  no 
doubt  that  the  middle-ear  infection  has  in  some  cases  influenced 
the  clinical  picture.  The  diagnosis  of  such  cases  is  almost  an 
impossibility  as  yet,  but  it  is  worth  while  to  keep  such  things  in 
view,  especially  as  they  influence  so  much  the  prognosis. 

1908-09. 

Southard,  E.  E.,  and  Mitchell,  H.  W.  Clinical  and  Anatom- 
ical Analysis  of  23  Cases  of  Insanity  arising  in  the  Sixth 
and  Seventh  Decades,  with  Especial  Relation  to  the  Inci- 
dence of  Arteriosclerosis  and  Senile  Atrophy  and  to  the 
Distribution  of  Cortical  Pigments.  Proceedings,  American 
Medico-Psychological  Association,  1908,  179-222.  Also  in 
American  Journal  of  Insanity,  Baltimore,  1908-09,  LXV, 
293-336. 

Conclusions. 
Arteriosclerosis  and  senility,  separately  or  combined,  have  been 
very  handy  terms  in  psychiatrical  diagnosis.  However,  we  be- 
lieve we  have  proved  conclusively,  by  the  present  analysis,  that 
neither  old-age  changes  nor  arterial  disease  have  any  necessary 
connection  with  the  development  of  insanity  in  the  later  years  of 
life,  at  least  in  the  sixth  and  seventh  decades.  It  seems  probable 
that  arteriosclerosis,  senility  and  various  forms  of  insanity  are 
entities  which  frequently  interpenetrate,  but  are  logically  and 
genetically  quite  separate.  Even  the  degree  to  which  old  age  and 
arterial  disease  serve  as  complicating  factors  in  insanity  has  been 
much  overestimated. 

The  constructive  part  of  our  paper  looks  in  the  direction  of  the 
distribution  of  intracellular  pigments,  a  species  of  work  harking 
back  to  the  somewhat  neglected  field  of  Bevan  Lewis  (1890). 
The  perivascular  cell  pigments,  according  to  our  comparisons, 
seem  to  afford  some  index  of  the  degree  of  faulty  metabolism  of 
the  cerebral  tissue;    these  pigments  are  deposited  in  like  amounts 


64 

throughout  a  given  brain.  The  neuroglia  cell  pigments,  in  the 
light  of  the  present  material,  vary  rather  with  the  age  of  the  indi- 
vidual. The  nerve-cell  accumulations  are  subject  to  the  greatest 
variations  even  in  a  single  brain,  certainly  do  not  vary  with  the 
age  of  the  individual,  and  vary  according  to  some  undetermined 
principle. 

We  have  omitted  literary  references  in  the  present  paper,  but 
wish  to  express  our  gratitude  to  Prof.  A.  M.  Barrett  for  the  use 
of  some  of  his  Danvers  Hospital  material.  Our  work  may  be  re- 
garded as  in  some  sense  a  complement  to  Barrett's  Study  of  Men- 
tal Diseases  associated  with  Cerebral  Arteriosclerosis  (American 
Journal  of  Insanity,  LXXII,  1,  1905).  Our  cases  are  from  the 
same  general  source  as  Barrett's  cases,  but  are  in  no  instance 
identical  therewith. 

It  would  be  of  some  value  to  fuse  with  the  present  analysis  a 
similar  analysis  of  the  frankly  organic  cases  of  the  same  epoch,  in 
order  to  pick  out,  if  possible,  the  special  constituents  of  the 
mental  picture  produced  by  the  gross  lesions.  This  task  we  have 
in  hand. 

Our  results  briefly  are:  — 

1.  Twenty-three  cases  of  insanity,  presumed  to  arise  in  the 
sixth  and  seventh  decades,  have  been  studied  clinically  and  ana- 
tomically. Two  of  these  were  alcoholic  in  origin.  Five  were 
paranoic.  Four  were  cases  of  delirium.  Three  were  maniacal. 
Xine  were  cases  of  depression. 

2.  Two  of  the  paranoic  cases  developed  katatoniform  symp- 
toms, and  might  be  placed  in  the  dementia  prsecox  group. 

Seven  cases  are  possibly  classifiable  in  the  manic-depressive 
group.  Two  of  these  had  attacks  of  retardation.  One  case  re- 
mained maniacal  for  thirteen  years.  One  recovered  from  a  single 
suicidal  depression  and  died  eight  years  later  of  intercurrent 
disease. 

3.  Neither  general  nor  cerebral  arteriosclerosis  bears  an  essen- 
tial causative  relation  to  the  insanities  developed  in  the  sixth  and 
seventh  decades  by  the  23  cases  clinically  and  anatomically 
studied. 

4.  The  insanities  arising  in  these  decades  are  not  character- 
istically due  to  the  premature  onset  of  senile  atrophy.  Eight  out 
of  11  female  brains  were  atrophic:  the  average  age  at  death  was 
69.8;  the  average  duration  10.8  years.  Five  out  of  12  male 
brains  were  atrophic:  the  average  age  at  death  was  65.6;  the 
average  duration  2.7  years. 


65 

Either  the  female  cases  are  more  liable  to  brain  atrophy  and 
to  live  longer  with  atrophied  brains,  or  else  the  atrophy  is  merely 
a  function  of  their  greater  age  at  death.  The  average  age  at 
death  in  all  11  females  is  67.2;  the  average  duration  8.8  years. 
The  average  age  at  death  in  all  12  males  is  62.3;  the  average 
duration  2.8  years.  The  differences  in  age  at  onset  —  female 
average  58.4  (atrophies,  59.8),  male  average  59.5  (atrophies, 
62.9)  —  are  not  great. 

5.  A  comparative  study  of  the  distribution  and  extent  in 
several  cortical  areas  of  certain  pigmented  materials  demonstrable 
by  iron-hematoxylin  (among  other  methods)  brings  out  extreme 
and  interesting  variations  in  the  cases  examined. 

Perivascular  cell  pigmentation  is  almost  uniform  in  different 
areas  of  the  same  case,  bar  focal  destructive  lesions,  but  varies  in 
degree  in  different  cases. 

Neuroglia  cell  pigmentation,  when  of  general  distribution,  prob- 
ably varies  more  or  less  directly  with  age. 

Nerve-cell  pigmentation  (iron-hematoxylin)  is  not  a  function 
of  age.  It  is  premature  to  relate  the  amounts  and  distributions 
of  nerve-cell  pigments  with  different  mental  diseases. 

Cotton,  H.  A.,  and  Southard,  E.  E.  A  Case  of  Central  Neuritis 
with  Autopsy.  American  Journal  of  Insanity,  Baltimore, 
1908-09,  LXV,  633-652. 

Summary  and  Conclusions. 

The  present  case  is  a  fresh  example  of  Adolf  Meyer's  central 
neuritis,  and  shows,  as  did  some  of  Meyer's  cases,  an  involve- 
ment of  the  peripheral  and  sympathetic  nervous  system,  to- 
gether with  the  central  nervous  system,  in  a  condition  of  severe 
and  extensive  lytic  change.  These  lytic  changes  are  exhibited  in 
characteristic  Marchi  degenerations  of  the  medullated  fibers,  and 
in  the  axonal  reaction  of  Nissl  in  certain  nerve-cell  types. 

These  fiber  and  cell  changes  are,  it  is  probable,  only  the  evi- 
dent fraction  of  a  large  series  of  changes  of  a  lytic  nature,  most 
of  which  cannot  be  demonstrated  by  present  histological  methods. 
Thus  the  Marchi  degenerations  invariably  surpass  in  amount  the 
axonal  reactions,  doubtless  because  many  of  the  fibers  which 
show  fat  drops  are  connected  with  cells  that  are  too  small  or  too 
scantily  supplied  with  Nissl  bodies  to  exhibit  the  axonal  reaction 
of  Nissl.     As  shown  by  the  Scharlach  method,  the  small  cells  have 


66 

undergone  a  serious  form  of  degeneration,  and  are  filled  with  fatty 
pigment. 

Another  evidence  of  the  universality  of  these  changes  is  the 
characteristic  reduction  of  consistence  on  the  part  of  both  the 
encephalon  and  the  cord.  Attention  has  been  called  to  this 
alteration  of  consistence  by  Southard  and  Hodskins.  In  the  case 
reported  by  them,  the  reduction  was  striking  in  all  parts  except 
an  area  of  sclerosis  in  one  hemisphere.  Examination  of  the 
tissues  by  the  Marchi  and  Nissl  methods  showed  that  the  pre- 
served nerve  cells  and  fibers  in  the  sclerotic  area  exhibited  the 
same  changes  as  the  cells  and  fibers  elsewhere.  The  disease, 
therefore,  seemed  due  to  some  lytic  agent  differential  for  nerve 
elements,  possibly  an  autolytic  agent.  The  present  case  again 
illustrates  the  generalized  reduction  of  consistence  of  central 
nerve  tissues  (general  encephalomalacia  and  myelomalacia),  to- 
gether with  some  indication  of  the  process  in  the  peripheral 
elements,  the  result,  perhaps,  of  a  lysis  or  autolysis  yet  more 
general   (neuromalacia). 

The  question  may  well  arise  whether  the  cells  or  the  fibers 
are  the  first  to  be  involved  in  the  lysis.  Despite  the  extent  and 
severity  of  the  Marchi  degenerations  in  the  medullated  fibers,  it 
is  nevertheless  probable  that  the  lysis  primarily  affects  the 
nervous  elements  rather  than  the  myelin  investments.  This 
point  ■  is  borne  out  by  the  extensive  changes,  simulating  the 
axonal  reaction,  in  the  nerve  cells  of  Auerbach's  plexus  in  the 
present  case.  Reasoning  from  this  finding  to  the  interpretation 
of  central  nervous  findings,  it  seems  possible  to  argue  that  the 
hypothetical  lytic  agent  attacks  elements  largely  proteid  in  char- 
acter. The  Cajal  fibril  preparations,  so  far  as  decisive,  are  con- 
sistent with  this  hypothesis.  The  nerve  cells,  stained  with  Schar- 
lach  Roth,  show  no  accumulations  of  fat  within  the  central  or 
chromatolyzed  area  in  the  first  stages  of  degeneration,  but  later, 
as  degeneration  proceeds,  the  whole  cell  is  filled  with  fatty  pig- 
ment. 

When  such  cytolytic  changes  prove  to  be  so  extensive  as  ia  the 
present  case,  involving  various  groups  of  axis-cylinders  and 
eventually  various  nerve  cell  bodies  and  nuclei,  as  well  as  myelin 
sheaths  in  many  regions,  it  may  well  be  that  the  change  here 
particularized  is  only  an  expression  of  a  still  more  general  lysis 
or  autolysis  which  will  be  best  attacked  along  chemical  lines. 


67 


1909. 

Southard,  E.  E.,  and  Richards,  E.  T.  F.  The  Lesions  of  Bacil- 
lary  Dysentery.  Boston  Medical  and  Surgical  Journal, 
1909,  CLXI,  694-703. 

Southard,  E.  E.  Conclusions  from  Work  on  the  Danvers  Dysen- 
tery Epidemic  of  1908.  Boston  Medical  and  Surgical  Jour- 
nal, 1909,  CLXI,  709-714. 

Southard,  E.  E.,  aided  by  McGaffin,  C.  G.  Nervous  System 
in  Bacillary  Dysentery.  Boston  Medical  and  Surgical 
Journal,  1909,  CLXI,  703-705. 

Conclusions. 

1.  The  brains  of  reduced  consistence  in  our  series  can  scarcely 
be  regarded  as  showing  effects  of  dysentery  toxin,  since  in  many 
cases  of  this  group  paraneuraxial  infection  with  other  organisms 
(terminal  or  secondary  invaders  of  the  cerebrospinal  fluid)  was 
established. 

2.  Organic  disease  of  the  central  nervous  system  has  no  special 
effect  in  favoring  fatal  issue. 

3.  Severe  fatty  degeneration,  demonstrated  by  the  Marchi 
method,  and  indicating  lesions  probably  of  several  days'  standing, 
was  characteristic  of  the  non-ulcerative  cases,  and  may  point  to  a 
differential  feature  in  the  organism  or  toxin  of  the  first  phase  of 
the  epidemic.  (See  Articles  IV,  VI  and  X.)  Or,  on  the  con- 
trary, this  finding  may  point  to  the  importance  of  secondary  in- 
fection in  dysentery. 

4.  Hemorrhagic  lesions  in  the  anterior  horns  of  the  spinal  cords 
were  not  present. 

5.  Two  cases  of  thrombosis  of  superficial  cerebral  arteries  have 
been  noted  in  cases  before  the  epidemic. 

Henderson,  L.  J.,  and  Southard,  E.  E.  The  Cultural  Value  of 
Certain  Medical  Studies  and  the  Elective  System  in  Medical 
Education.  Boston  Medical  and  Surgical  Journal,  1909, 
CLXI,  981-983. 

Remarks. 
All  that  we  contend  for  in  the  matter  which  Professor  D wight 
has  discussed  is,  first,  that  there  are  broadly  scientific  courses  in 
the  medical   school   whose  nature  is  fixed   by  the  consensus  of 


68 

opinion  of  the  teachers  of  such  subjects  throughout  the  world; 
and  secondly,  that  it  is  at  least  an  open  question,  not  to  be 
settled  by  a  judgment  ex  cathedra  or  on  medical  grounds,  whether 
or  not  they  are  well  suited  to  count  for  the  bachelor's  degree. 

Southard,  E.  E.,  and  Henderson,  L.  J.  Education  in  Medicine. 
(Letter.)  Boston  Medical  and  Surgical  Journal,  1909, 
CLXI,  948-949. 

Gay,  F.  P.,  Southard,  E.  E.,  and  Fitzgerald,  J.  G.  Neuro- 
physiological  Effects  of  Anaphylactic  Intoxication.  Journal 
of  Medical  Research,  Boston,  1909,  XXI,  21-40.  (New 
series,  Vol.  XVI.) 

Summary  and  Remarks. 

The  work  of  Gay  and  Southard  upon  the  localization  of  cell 
and  tissue  anaphylaxis  (serum  type)  in  the  guinea  pig  has  been 
continued.  The  work  of  1908  had  brought  out  sharply  the  strict 
comparability  of  intravascular  and  orbital  injections  in  their 
capacity  to  produce  violent  respiratory  symptoms  or  death.  As 
was  then  stated,  "  The  occurrence  and  rapidity  of  death  in  the 
critical  phase,  as  well  as  the  severity  of  respiratory  symptoms 
throughout  the  toxic  phase,  appear  to  vary  with  the  nearness  of 
the  toxic  injections  to  the  respiratory  central  apparatus." 

But  evidence  was  further  adduced  to  show  that  the  sensitiza- 
tion of  the  respiratory  centers  was  but  relative,  and  that  those 
who  claim  that  the  toxic  effects  are  due  to  a  specifically  respira- 
tory toxin  are  inexact. 

The  theoretical  significance  of  injections  alongside  the  nervous 
system  (paraneuraxial  injections)  was  shown  to  consist  in  the 
capacity  of  such  injections  to  spread  directly  through  the  cerebro- 
spinal fluid  to  the  respiratory  centers.  Such  direct  paraneu- 
raxial drenching  of  the  sensitized  nervous  system  was  shown  both 
theoretically  and  experimentally  to  be  approximately  equivalent 
to  intoxication  by  the  intravascular  route. 

The  evidence  from  paraneuraxial  injections  has  now  been 
strengthened,  and  so  supported  by  evidence  from  several  kinds  of 
intraneuraxial  injections  as  to  warrant  confirmation  of  our  tenta- 
tive statement  of  1908,  "that  differential  irritative  and  paralytic 
reactions  can  be  secured  by  small  localized  injections  of  horse 
serum  adjacent  to  various  parts  of  the  sensitized  central  nervous 
system." 


69 

The  most  lethal  form  of  paraneuraxial  injection  is  the  orbital. 
The  orbital  method  of  injection  is  the  method  of  election  for 
determining  toxicity,  in  Besredka's  sense,  since  the  complicating 
features  of  intravascular  injection  and  of  trephining  are  avoided. 
The  orbital  method  permits  immediate  drenching  of  the  bulb 
through  the  cerebrospinal  fluid. 

Many  varieties  of  paraneuraxial  injection  have  been  practiced. 
To  secure  non-respiratory  phenomena  and  avoid  lethal  outcome, 
it  is  only  necessary  to  inject  the  serum  into  the  muscular  and 
interstitial  tissues  outside  the  nervous  system,  thus  permitting  a 
slower  absorption  and  a  differentiation  of  results  analogous  to 
that  secured  by  comparative  intraperitoneal  and  subcutaneous 
injections. 

Both  irritative  and  paretic  non-respiratory  symptoms  can  be 
produced  by  paraneuraxial  injections  of  various  dosage  appro- 
priately localized. 

It  is  not  probable  that  these  paraneuraxial  injections  act  by 
intoxicating  the  nerves  suspended  in  the  cerebrospinal  fluid;  at 
any  rate,  no  comparable  degree  of  intoxication  has  been  secured 
by  paraneural  applications  of  serum  outside  the  enclosing  sheath 
of  the  central  nervous  system  (trigeminus,  sciatic  nerve).  Nor 
has  death  ever  followed  applications  to  the  vagus  in  its  extradural 
course  despite  the  production  of  severe  respiratory  symptoms 
thereby. 

Intraneuraxial  injections  (e.g.,  intracerebellar,  intramyelic,  in- 
tracerebral) in  sensitized  animals  effect  a  variety  of  symptoms, 
sometimes  irritative,  sometimes  paretic.  It  is  easy  to  distinguish 
respiratory  and  non-respiratory  phenomena. 

Intramyelic  injections  in  the  cervical  region  produce  not  merely 
the  expected  respiratory  symptoms,  but  also  brachial  paraplegia. 

The  effects  of  .intracerebellar  injections  must  be  interpreted 
with  caution,  on  account  of  symptoms  producible  by  purely  me- 
chanical means.  Opisthotonus  and  nystagmus  appear  to  be 
characteristic  of  anaphylactic  intoxication.  But  with  respect  to 
nystagmus,  the  proximity  of  the  restiform  body  and  of  the  cor- 
pora quadrigemina  must  be  considered. 

Intracerebral  injections  produce  a  variety  of  symptoms,  such 
that  the  locus  of  injection  becomes  important  to  consider.  We 
are  able  to  distinguish  a  motor  from  a  sensorimotor  (olfactory) 
type  of  reaction.  These  observations  open  a  field  of  considerable 
neurological  interest,  since  heretofore  electrical  stimulation  in 
normal  animals  has  been  the  best  means  of  attack  on  localizing 


70 

problems.  Obviously  extirpation  experiments  before  and  after 
sensitization  and  subsequent  anaphylactic  intoxication  will  un- 
earth many  novel  facts. 

We  are  not  disposed  to  emphasize  unduly  the  dualistic  or 
anaphylactin  hypothesis  of  Gay  and  Southard  as  applied  to  the 
phenomena  of  anaphylaxis.  We  would  only  once  more  call  to  the 
attention  of  the  supporters  of  the  antibody  hypothesis  how  much 
more  difficult  that  hypothesis  becomes  in  case  the  alleged  anti- 
bodies are  intracellular  and  lodge  in  varying  degree  in  different 
loci  of  the  nervous  system  as  well  as  elsewhere  in  the  body. 

Southard,  E.  E.  A  Study  of  Errors  in  the  Diagnosis  of  General 
Paresis.  (Abstract.)  Journal  of  Nervous  and  Mental  Dis- 
ease, Lancaster,  Pa.,  and  New  York,  1909,  XXXVI,  545- 
549.  Also  in  Journal  of  Nervous  and  Mental  Disease, 
Lancaster,  Pa.,  1910,  XXXVII,  1-16. 

Conclusions. 

1.  An  effort  has  been  made  to  establish  the  accuracy  of  diag- 
nosis in  general  paresis.  The  method  has  been  to  analyze  clini- 
cally the  data  of  cases  in  which  several  experienced  workers  h.id 
agreed  upon  the  diagnosis,  and  to  compare  their  findings  with  the 
anatomical  and  histological  data  of  the  autopsies. 

2.  Thirty-five  out  of  41  cases  unanimously  diagnosed  general 
paresis  ante  mortem  proved  to  be  cases  of  general  paresis  (85 
per  cent  accuracy). 

3.  Six  cases  of  erroneous  diagnosis  have  been  especially  studied. 
None  of  these  showed  plasma  cells  in  the  nerve  tissues  (Nissl's 
methylene  blue  and  L.  Ehrlich's  pyronin  methods),  but  all  showed 
a  variety  of  lesions  which  warrant  placing  them  in  an  "organic" 
group. 

4.  The  lesions  probably  responsible  for  the  errors  in  diagnosis 
were:  (a)  Meningomyelitis  and  subcortical  encephalitis  (luetic?), 
Case  V;  (6)  tabes  dorsalis  and  non-paretic  cerebral  disease,  Cases 
I,  IV;  (c)  arteriosclerotic  brain  disease  with  severe  cerebellar  in- 
volvement (dentate  nuclei),  Cases  II,  VI;  (d)  cerebral  sclerosis 
(type,  perivascular  gliosis),  Case  III. 

5.  Although  at  first  sight  a  probable  error  of  15  per  cent  in 
the  diagnosis  of  general  paresis  might  suggest  difficulties  in  pos- 
sible medicolegal  cases,  it  is  obvious  that,  were  the  diagnosis  con- 
fined to  "incurable  insanity"  or  even  to  "organic  brain  disease," 
the  error  would  disappear.     However,  2  cases  proved  to  be  gen- 


71 

eral  paresis  (on  the  plasma-cell  criterion)  in  a  series  of  186 
cases  similarly  examined  in  which  the  diagnosis  of  general  paresis 
was  not  considered. 

6.  Improvements  in  our  diagnostic  ability  could  perhaps  be 
introduced  by  lumbar  puncture  and  cytological  examination  in  a 
greater  proportion  of  cases.  But  it  is  doubtful  whether  3  of  the 
,6  errors  here  studied  would  have  been  resolved  by  cyto-diagnosis 
(meningomyelitis,  tabes  dorsalis).  One  other  case  (VI,  arterio- 
sclerotic brain  disease)  actually  did  show  plasma  cells  in  the  lum- 
bar puncture  fluid,  the  source  of  which  was  not  made  out  at 
autopsy. 

Henderson,  L.  J.,  Ph.D.,  and  Southard,  E.  E.  Education  in 
Medicine.  The  Relations  of  the  Medical  School  and  the 
College.  The  Harvard  Bulletin,  Nov.  3,  1909,  XII,  1-3  and 
6.     See  also  Science,  1909,  XXX,  679-680. 

Southard,  E.  E.,  and  Henderson,  L.  J.  Education  in  Medicine. 
The  Elevation  of  the  Medical  Directorate.  The  Harvard 
Bulletin,  Dec.  8,  1909,  XII,  2. 

Southard,  E.  E.  Communication:  Cultural  Value  of  the  Medi- 
cal Sciences.    The  Harvard  Bulletin,  Dec.  15,  1909,  XII. 


1910. 

Putnam,  J.  J.,  and  Southard,  E.  E.,  aided  by  Ruggles,  A.  H. 
Observations  on  a  Case  of  Protracted  Cerebrospinal  Syphilis 
with  Striking  Intermittency  of  Symptoms:  Attempt  at  Cor- 
relation with  Ascending  Meningomyelitis,  Cranial  Neuritis, 
Subcortical  Encephalitic,  and  Focal  Encephalomalacia  found 
at  Autopsy.  Journal  of  Nervous  and  Mental  Disease,  1910, 
XXXVII,  145-163. 

Conclusions. 

The  very  varied  problems  and  considerations  of  this  case  may 
be  set  forth  as  follows:  — 

1.  A  protracted  case  of  cerebrospinal  syphilis  shows  at  the 
end  of  sixteen  years  after  infection  and  eleven  years  after  initial 
nerve  symptoms  a  multiplicity  of  chronic  lesions,  but  shows  few 
acute  lesions  save  (a)  lymphocytic  exudation  in  the  upper  spinal 
cord  segments   (preferring  the    posterior  root  regions),   and    (6) 


72 

certain  interesting  leukeneephalitic  foci  in  the  brain.  Possibly 
both  (a)  and  (b)  are  related  to  intercurrent  infection  from  exten- 
sive decubitus;  this  is  more  likely  in  the  case  of  (&).  Search  for 
spirochetal  so  far  negative. 

2.  On  the  basis  of  gross  and  histological  findings  it  is  possible 
to  correlate  many  of  the  various  clinical  features:  (a)  trans- 
verse myelitis,  (b)  intermittent  cranial  nerve  and  other  symptoms, 
with  structural  disorder.  But  there  were  hysterical  tendencies 
throughout  which  rendered  exact  correlations  difficult  intra  vitam. 

3.  The  intermittency  of  symptoms  just  mentioned  2  (b)  was 
most  striking,  and  an  enumeration  of  histological  possibilities 
is  given  which  might  account  for  this  intermittency  (acute  and 
reparative  changes  in  the  pia  mater;  cellular  and  fibrillar  gliosis, 
whether  nuclear,  periradicular,  or,  in  some  cases,  intra -radicular; 
and  the  corset-like  contraction  of  whole  regions  subject  to 
sclerosis,  with  consequent  herniation  of  small  bits  of  nerve 
tissue). 

4.  The  intermittency  and  varied  structural  origin  of  the  symp- 
toms, as  well  as  the  maintenance  to  the  last  of  acute  changes 
mentioned  under  1,  are  reasons  for  optimism  in  pushing  anti- 
syphilitic  treatment. 

5.  Incidentally,  the  post-mortem  data  show  how  lumbar 
puncture  might  fail  to  reveal  lymphocytes  in  cerebrospinal 
syphilis,  provided  that  there  is  an  occlusion  of  the  intermeningeal 
space  by  adhesions  above  the  point  of  puncture. 

6.  The  case  presented  a  kind  of  reversal  of  the  biological 
tendency  that  the  structures  later  evolved  shall  be  destroyed  first, 
since  the  course  of  lesions  in  this  case  was  largely  ascending 
throughout,  and  the  cerebral  cortex  was  left  at  the  last  a  species 
of  shell  from  which  the  lower  functioning  mechanisms  had  been 
successively  scooped  out  by  disease. 

Southard,  E.E.  Anatomical  Findings  in  Senile  Dementia:  A 
Diagnostic  Study  bearing  especially  on  the  Group  of  Cerebral 
Atrophies.  American  Journal  of  Insanity,  Baltimore,  1909- 
10,  LXVI,  673-708.  Also  in  Proceedings,  American  Medico- 
Psychological  Association,  1909,  XVI,  511-548. 

Summary  and  Conclusions. 
1.  Forty-two  cases  unanimously  diagnosed  "senile  dementia" 
at  the  Dan  vers  Hospital  clinics  have  been  reviewed  clinically  and 
anatomically,  with  a  surprisingly  low  general  percentage  of  ac- 


73 

curacy  (66  per  cent)  where  either  cerebral  atrophy  or  cortical 
arteriosclerosis  or  both  were  regarded  as  confirmatory,  and  with 
still  lower  percentages:  (48  per  cent)  where  cortical  arterioscle- 
rosis was  considered  essential,  and  (38  per  cent)  where  cerebral 
atrophy  was  considered  essential,  for  a  correct  diagnosis. 

2.  The  14  cases  which  showed  neither  cerebral  atrophy  nor 
cortical  arteriosclerosis  (with  obvious  damage  to  the  cortical 
tissues)  are  cases  which  probably  should  not  have  been  termed 
senile  dementia,  and  perhaps  more  properly  belong  in  a  group  of 
acute  psychoses  or  other  mental  diseases  occurring  in  old  age  but 
not  dependent  on  recognizable  senile  changes. 

3.  Of  the  residuum,  it  is  clear  that  cases  in  which  cerebral 
atrophy  and  cortical  arteriosclerosis  are  combined  are  not  suitable 
for  exact  study,  and  attention  has  been  concentrated  upon  eight 
cases  of  relatively  pure  brain  atrophy,  regarded  as  representing 
more  nearly  genuine  senile  dementia  than  the  arteriosclerotic 
cases,  which  should  be  classed  under  the  head  of  organic  dementia. 

4.  True  senile  or  senile  atrophic  dementia  includes  (1)  cases  in 
which  the  loss  in  brain  weight  proceeds  pari  passu  with  a  general 
loss  of  weight  in  the  other  viscera,  and  (2)  cases  in  which  the  loss 
in  weight  of  the  nerve  tissues  is  differential. 

5.  The  mental  diseases  of  old  age,  therefore,  include  — 

(a)  Mental  diseases  occurring  in,  but  not  characteristic  of, 
old  age. 

(6)  Organic  dementias  due  to  cortical  arteriosclerosis. 

(c)  Senile  atrophic  dementias,  attended  with  (1)  general  vis- 
ceral atrophy  and  (2)  differential  atrophy  of  the  nerve  tissues. 

6.  Obvious  suggestions  for  research  in  the  two  groups  of  senile 
atrophic  dementias  as  above  stated  are  that  the  phenomena  of 
general  visceral  atrophy  may  depend  upon  general  decadent 
agencies  (dehydration?),  and  that  the  more  differential  atrophy 
indicates  special  metabolic  flaws  or  toxic  agencies. 

7.  Since  such  a  grouping  has  not  been  hitherto  rigorously  borne 
in  mind,  it  is  not  possible  to  state  the  clinical  features  of  these 
cases  in  detail. 

8.  Taking  the  group  senile  atrophic  dementia  as  a  whole,  we 
find  all  the  eight  cases  female,  without  special  indications  of  in- 
heritance, with  very  various  antecedent  factors  (social  factors  not 
prominent),  all  markedly  defective  in  vision  (though  for  a  con- 
siderable variety  of  reasons),  often  defective  in  hearing,  all  sub- 
ject to  various  degrees  of  arteriosclerosis  (in  some  instances  not 
clinically  made  out),  all  showing  the  characteristic  external  signs 


74 

of  senility,  and  all  showing  either  chronic  diffuse  nephritis  (inter- 
stitial type  predominant)  or  renal  arteriosclerosis'. 

9.  Neurologically,  the  eight  cases  showed  characteristically 
tremors,  absence  of  certain  superficial  reflexes,  variations  in  some 
deep  reflexes  (tendency  to  loss  of  leg  reflexes),  defective  organic 
reflexes,  alterations  of  gait,  and  occasional  slight  speech  disorder. 

10.  Psychiatrically,  communication  with  the  patients  is  difficult 
and  impressibility  or  general  perceptual  capacity  is  deficient. 
The  amnesia  for  recent  events  is  characteristic  and  constant. 
The  patients  are  perhaps  unoriented  rather  than  disoriented. 
Amnesia  for  remote  events  is  also  frequently  present.  Delusions 
are  not  prominent.  Visual  or  auditory  hallucinations  (or  illu- 
sions) characterized  some  cases.  Motor  excitement  and  nightly 
restlessness  and  noise  are  characteristic,  though  not  quite  con- 
stant, and  are  not  in  all  cases  certainly  due  to  hallucinations. 
Garrulity  was  surprisingly  uncommon  in  this  group. 

11.  Anatomically  the  pia  mater  was  in  general  remarkably  free 
from  chronic  changes,  and,  as  the  condition  of  the  vessels  was  the 
basis  of  selection  of  the  cases,  the  vessels  naturally  showed  noth- 
ing grossly  beyond  involvement  of  the  larger  or  pipe  arteries 
(basal  cerebral  arteriosclerosis).  The  cerebral  wasting  was  not 
in  all  cases  quite  uniform.  One  case  even  showed  a  slight  granu- 
lar ependymitis.  The  consistence  of  the  brain  tissue  was  in  gen- 
eral increased. 

12.  A  high  percentage  of  obsolete  tuberculosis  characterized  the 
autopsies. 

13.  Aortic  sclerosis  is  probably  constant  in  these  cases. 
Sclerosis  of  other  vessels  is  frequent  but  variable.  The  constancy 
of  renal  changes  is  interesting. 

14.  The  cause  of  death  is  pulmonary  in  many  cases,  and  is  per- 
haps in  some  way  bacterial  in  all. 

15.  No  intensive  microscopic  examination  has  been  under- 
taken, as  the  object  has  been  rather  to  define  the  group  of  senile 
atrophic  dementias.  The  satellite  cell  findings  are  consistent  with 
Metchnikoff's  hypothesis  concerning  phagocytic  processes  in  old 
age.  It  is  believed,  however,  that  cell  and  fiber  changes  are  very 
probably  primary  and  "neuronophagia"  secondary,  or  at  any 
rate  that  these  processes  run  pari  passu. 

16.  A  few  cases  showed  satellite  cells  preferring  the  apical  cell 
processes  rather  than  the  basal  regions  of  the  pyramidal  cells. 

17.  It  is  alleged  that  no  convincing  evidence  has  been  brought 
of  a  causal  relation  between  local  vascular  changes  and  diffuse 
senile  nerve-cell  atrophy. 


75 

Southard,  E.  E.  Acute  Encephalitis  and  Brain  Abscess.  In 
Osier's  "Modern  Medicine,"  1910,  VII,  624-653.  Also  in 
second  edition,  1915,  V,  359-386. 

Southard,  E.  E.,  and  Fitzgerald,  J.  G.  Discussion  of  Psychic 
and  Somatic  Factors  in  a  Case  of  Acute  Delirium  dying  of 
Septicemia:  Note  upon  Experimental  Guinea  Pig  Infection 
with  Staphylococcus  Albus.  Boston  Medical  and  Surgical 
Journal,  1910,  CLXII,  452-458. 

Discussion. 

It  is  possible,  by  shifting  the  emphasis  in  a  clinical  history,  to 
convey  two  quite  separate  notions  as  to  the  genesis  of  a  given 
case  of  mental  disease.  Yet  an  answer  to  the  question  whether 
somatic  or  psychic  (hereditary,  individual,  social)  factors  are  the 
more  important  in  many  cases  of  mental  disease  would  be  de- 
cisive in  the  inclination  of  research  upon  these  factors.  It  is  our 
opinion  that  research  should  be  inclined  upon  the  side  of  the 
bacteria  and  the  toxins  in  appropriate  cases. 

Although  no  single  logical  step  in  the  process  is  absolutely 
safe,  we  feel  that  a  reasonable  account  of  our  case  might  be  as 
follows:  — 

1.  A  cluster  of  nervous  symptoms,  compounded  from  the 
effects  of  uterine  growths  and  unhappy  married  life. 

2.  Latent  blood  infection  (staphylococcus  albus  bacteriemia) 
possibly  related,  through  some  unidentifiable  atrium  of  infection, 
with  acne. 

3.  Rapid  and  massive  enlargement  of  uterine  growths  (deter- 
mining in  some  obscure  way  the  sexual  trend  of  symptoms?)  and 
pressure  upon  the  iliac  veins. 

4.  Thrombosis  of  iliac  veins  and  vena  cava  (date  not  clear, 
possibly  at  the  onset  of  the  mental  symptoms,  possibly  fifteen 
days  later)  and  its  sequela?. 

5.  Acute  delirium,  difficult  logically  either  to  connect  with  or 
to  disconnect  from  the  thrombosis  and  bacteriemia  discovered  at 
autopsy. 

6.  Death  from  septicemia  and  pulmonary  thrombosis. 

The  case  detailed  above  raises  the  question  whether  the  in- 
cidence of  bacteria  of  low  toxicity  can  determine  insanity  of  the 
type  of  acute  delirium.  Many  textbooks  seem  to  admit  some- 
thing of  the  sort  in  their  groups  of  infectious  deliria.  It  must  be 
conceded,  however,  that  the  precise  relationship  of  infection  to 
delirium  in  its  psychiatric  sense  is  still  far  from  clear. 


76 

As  to  the  toxic  value  of  staphylococcus  albus,  writers  are  not 
wholly  clear.  Genuine  cases  of  albus  septicemia  are  not  un- 
known. The  remarkable  work  of  Winslow  on  the  Coccaceae  has 
served  to  unify  rather  than  separate  the  staphylococci  of  various 
sorts.  Kraus  and  Pribram  (1906)  have  shown  that  many 
varieties  of  staphylococci  produce  a  true  toxin  which  will  pass 
into  the  culture  nitrate  and  produce  an  antitoxin;  the  toxin  in 
question  appears  to  poison  the  heart  especially.  Panichi  (1906) 
was  able  to  cultivate  the  albus  repeatedly  over  weeks  and  months 
from  the  blood  of  two  subjects  who  otherwise  gave  no  note- 
worthy signs  of  infection.  Similar  results  with  other  organisms, 
especially  in  convalescence,  are  serving  to  overthrow  our  older 
notions  of  the  essential  injuriousness  of  bacteriemia.  Such  bac- 
teriemia  of  unknown  atrium  may  readily  permit  infection  and 
thrombosis  of  tissues  under  such  conditions  as  those  of  the  iliac 
veins  in  the  case  above  described.  Moreover,  it  does  not  overstep 
the  bounds  of  probability  to  state  that  a  variety  of  symptoms, 
among  them  mental,  may  accrue  from  such  low-grade  infections. 

The  hypothesis  that  drug-like  products  of  bacteria,  or  bacteria 
themselves  drug-like  in  action,  may  produce  mental  symptoms  is 
certainly  far  from  unlikely,  though  it  is  also  true  that  idiosyn- 
crasy or  special  sensitization  may  be  essential  to  permit  the 
development  of  such  symptoms. 

It  is  obvious,  however,  that  psychiatric  clinics  are  not  working 
this  field  intensively,  and  for  such  work  we  wish  to  put  in  a  plea. 
Routine  blood  cultures  and  carefully  chosen  immunity  tests 
(especially  those  just  recently  developed  for  other  purposes  as  a 
result  of  the  work  of  Bordet  and  others)  in  such  cases  would  go  far 
to  clear  up  these  obscure  relations.  Perhaps  only  by  such  intensive 
work  can  the  mechanism  of  certain  types  of  insanity  be  learned. 

Gay,  F.  P.,  and  Southard,  E.  E.  The  Significance  of  Bacteria 
cultivated  from  the  Human  Cadaver:  A  Study  of  100  Cases 
of  Mental  Disease,  with  Blood  and  Cerebrospinal  Fluid. 
Cultures  and  Clinical  and  Histological  Correlations.  Cen- 
tralblat  f.  Bakteriologie  (etc.),  1.  Abt.,  Jena,  1910,  LV, 
Orig.,  117-133.  (From  the  Laboratory  of  the  Danvers  State 
Hospital.) 

Conclusions. 
1.  The  results  of  bacterial  cultivations  from  the  heart's  blood, 
and  the  cerebrospinal  fluid  post  mortem  in  100  cases  of  mental 
disease,  have  been  correlated  with  the  histopathological  findings 


77 

(Marchi  impregnations  of  the  spinal  cord  at  three  levels)  and  the 
clinical  histories,  having  special  reference  to  a  history  of  terminal 
disease  over  or  under  four  days'  duration  (regarded  as  a  period 
in  which  typical  Marchi  alterations  might  ensue). 

2.  The  bacteria  were  cultivated  upon  agar  plates  inoculated 
with  1  to  1.5  cubic  centimeters  heart's  blood  and  others  with  the 
same  amount  of  cerebrospinal  fluid.  The  cerebrospinal  fluid  was 
removed  from  the  third  ventricle  through  the  infundibulum, 
severed  at  its  origin. 

3.  Forty-one  per  cent  of  our  heart's  blood  cultures  remained 
sterile  (c/.  Gradwohl,  22  per  cent;  Otten,  42  per  cent;  Simmonds, 
48  per  cent). 

4.  Twenty-eight  per  cent  of  the  cerebrospinal  fluid  cultures 
remained  sterile. 

5.  Under  the  conditions  of  our  laboratory  the  statistics  show 
(Table  I)  that  there  is  no  significant  difference  in  the  percentage 
of  positive  cultures  from  either  source  at  varying  hours  post 
mortem,  and  that  the  danger  of  contamination  must  be  limited 
to  a  brief  interval  after  death. 

6.  Our  findings  point  definitely,  if  indirectly,  to  the  intravital 
significance  of  the  bacteria  found,  despite  the  fact  that  in  no 
particular  instance  is  the  chain  of  evidence  complete. 

7.  Since  the  same  bacteriolytic  substances  are  found  in  blood 
serum  both  before  and  for  some  time  after  death,  there  is  no 
reason  for  supposing  that  bacteria  can  grow  better  post  mortem. 

8.  We  now  show  that  bacteriolytic  substances  are  absent  in 
the  cerebrospinal  fluid,  so  that  there  appears  to  exist  therein  no 
extracellular  mechanism  for  the  disposal  of  bacteria. 

9.  The  fact  just  stated  (7  and  8)  may  account  for  the  higher 
percentage  of  organisms  in  the  cerebrospinal  fluid. 

10.  Among  the  facts  concerning  the  incidence  of  bacterial  forms 
(Table  II)  are  these:  cocci  were  found  in  the  blood  in  26  cases, 
in  the  cerebrospinal  fluid  in  34  cases;  streptococci,  blood,  8 
times,  cerebrospinal  fluid,  twice;  pneumococci,  blood,  3  times; 
B.  coli  aerogenes  group,  blood,  11  times,  cerebrospinal  fluid,  25 
times;    B.  proteus  group,  cerebrospinal  fluid,  7  times. 

11.  The  absence  of  diphtheroid  organisms  from  our  series  is 
noteworthy,  since  in  previous  years  cultivations  at  the  Danvers 
Hospital  had  yielded  such  organisms  in  several  cases. 

12.  Cultivations  from  thirteen  general  paretics  are  listed 
(Table  III);    in  the  positive  cases  cocci  prevail. 

13.  Nine    bacteriologically    negative    cases    are    listed    (Table 


78 

IV);    reasons  are  adduced  for  certain  histopathological  changes, 
possibly  independent  of  bacteria,  in  these  cases. 

14.  Ten  cases  which  failed  to  show  specified  histopathological 
changes  are  listed  (Table  V),  from  which  it  appears  that  coli 
is  not  found  associated  with  such  cases  unless  the  terminal  dis- 
ease happens  to  have  been  brief.  On  the  other  hand,  cocci  are  a 
frequent  finding  in  this  group. 

15.  Thirty-one  cases  which  had  terminal  symptoms  less  than 
four  days  in  duration  are  listed  (Table  VI);  29  per  cent  of  these 
failed  to  show  spinal  cord  degenerations  by  the  Marchi  method 
(as  against  10  per  cent  in  the  total  series). 

16.  Of  10  cases  selected  as  showing  most  numerous  spinal 
fatty  degenerations  (diffusely  scattered  blackenings  in  white  and 
gray  matter),  9  showed  coli  communis  either  in  heart's  blood  or 
in  cerebrospinal  fluid  or  in  both,  and  8  in  large  numbers. 

17.  Of  18  cases  yielding  40  or  more  colonies  of  coli  communis 
from  one  or  each  source,  8  showed  extreme  degrees  of  Marchi 
degeneration,  5  relatively  severe  changes  (intraspinal  and  intra- 
radicular),  and  the  5  remaining  cases  showed  considerable  intra- 
spinal change. 

IS.  Of  13  cases  showing  generalized  softening  of  brain  tissue 
(general  encephalomalacia),  10  yielded  coli  communis. 

19.  A  definite  relation  must  be  assumed  to  exist  between  coli 
communis  or  its  toxines  and  nerve-fiber  degeneration. 

Southard,  E.  E.  The  Laboratory  Work  of  the  Danvers  State 
Hospital,  Hathorne,  Mass.,  with  Especial  Relation  to  the 
Policy  formulated  by  Dr.  Charles  Whitney  Page,  Super- 
intendent, 1888-98,  1903-10.  Boston  Medical  and  Surgical 
Journal,  1910,  CLXIII,  150-155. 

Remarks. 
What  has  been  brought  out  in  extenso  refers  to  the  more  purely 
scientific  side  of  the  Danvers  work,  as  largely  favored,  advocated 
and  mechanized  by  Dr.  Page,  to  whom  we  wish  to  present  the 
product  of  our  recent  work  in  the  articles  of  this  series.  The 
chief  considerations  are  as  follows:  — 

1.  The  insane  hospital  gets  no  vital  support  from  a  medical 
profession  ill-educated  in  mental  disease. 

2.  The  situation  is  apt,  in  America  at  large,  to  be  dominated 
by  the  per  capita  cost  rather  than  by  the  humanitarian  considera- 
tions which  underlie  the  whole  system  of  treatment  of  the  insane. 


79 

3.  The  superintendency  of  a  State  hospital  for  the  insane  has 
become  a  position  requiring  generalship;  is  strategic  rather  than 
tactical. 

4.  Since  the  superintendent  has  oversight  of  the  science  as 
well  as  the  art  of  psychiatry,  as  exemplified  in  his  hospital,  it 
becomes  his  duty  continually  to  improve  the  laboratory  as  well  as 
the  ward  facilities,  and  this  in  the  interest  of  the  patient. 

5.  Dr.  Page's  Danvers  work  has  contributed  to  the  economics 
underlying  the  proper  co-ordination  of  the  two  aspects  —  the 
ward  and  laboratory  aspects  —  of  the  large  problem  of  diagnosis 
and  treatment  of  insane  patients  in  State  hospitals. 

6.  Special  attention  may  be  drawn  (a)  to  the  appointment  of 
specially  (though  very  variously)  trained  men  to  the  pathologist- 
ships;  (b)  to  the  encouragement  by  maintenance  of  special  labo- 
ratory internes;  (c)  to  the  daily  clinic  system  with  its  republican 
feature  of  rotating  leaders;  and  (d)  to  the  complete  index  of 
symptoms  now  on  file  for  all  Danvers  patients. 

7.  The  maintenance  of  clinico-pathological  laboratories  in 
State  hospitals  for  the  insane  is  argued  as  a  method  for  general 
adoption  on  account  of  improvements  in  diagnosis,  and  hence  in 
treatment,  which  follow  their  establishment. 

Southard,  E.  E.  The  Margin  of  Error  in  the  Diagnosis  of 
Mental  Disease:  Based  on  a  Clinical  and  Anatomical  Re- 
view of  250  Cases  examined  at  the  Danvers  State  Hospital, 
Massachusetts,  1904-08.  Boston  Medical  and  Surgical 
Journal,  1910,  CLXIII,  155-159. 

Summary. 

1.  A  series  of  250  cases  of  mental  disease,  with  intra-vitam 
diagnoses  by  several  physicians,  recorded  at  the  Danvers  State 
Hospital  daily  clinics,  1904-08,  has  been  subjected  to  anatomical 
review  for  the  sake  of  learning  where  lie  the  greatest  difficulties 
in  diagnosis. 

2.  Ten  cases  (4  per  cent)  remain  both  clinically  and  anatomi- 
cally obscure. 

3.  Seven  cases  (2.8  per  cent)  had  diagnostic  doubts  settled 
after  the  clinic  either  intra-vitam  or  post  mortem  (one  case  each  of 
general  paresis,  cortical  arteriosclerosis,  cerebral  sclerosis  with 
Graves'  disease,  streptococcus  septicemia,  epilepsy,  streptococcus 
meningitis,  cerebellar  abscess). 

4.  Sixty-six  cases   (26  per  cent)   were  doubtful  clinically,  but 


80 

the  correct  diagnosis  was  obtained  by  one  or  more  diagnosticians 
in  49  of  the  66  (74  per  cent  of  the  doubtful  group). 

5.  One  hundred  and  eighty-four  cases  (74  per  cent)  were 
clinically  certain,  and  the  clinical  diagnoses  were  confirmed  (or 
not  altered)  by  autopsy  in  163  of  the  184  (89  per  cent  of  the 
unanimous  group). 

6.  The  correct  diagnosis  was  obtained  by  one  or  more  diag- 
nosticians in  49  +  163  =  212  cases  in  250  (85  per  cent). 

7.  The  "correctness"  of  these  diagnoses  is  subject  to  some 
reservation,  (1)  since  within  the  "organic  and  senile  dementia 
group"  differentiation  proved  difficult,  and  (2)  since  anatomical 
"consistency"  often  signifies  absence  of  characteristic  lesions. 
The  acute  psychoses  have  been  reviewed,  however,  bearing  in 
mind  modern  views.  Several  alcoholic  cases  failed  to  exhibit 
striking  brain  lesions. 

8.  The  majority  of  the  real  diagnostic  difficulties  uncovered  by 
this  analysis  would  appear  to  require  more  intensive  work  in  the 
field  of  clinical  pathology.  For  such  work  in  psychopathic  hos- 
pitals this  paper  is  an  appeal. 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  Bacterial  In- 
vasion of  the  Blood  and  Cerebrospinal  Fluid  by  Way  of 
Mesenteric  Lymph  Nodes:  A  Study  of  50  Cases  of  Mental 
Disease.  Boston  Medical  and  Surgical  Journal,  1910, 
CLXIII,  202-209. 

Summary. 

1.  Following  the  same  technic  chosen  by  Gay  and  Southard 
for  their  study  of  the  post-mortem  bacteriology  of  the  heart's 
blood  and  cerebrospinal  fluid  in  100  cases  of  mental  disease,  the 
writers  have  examined  50  further  cases  from  the  same  source 
(Danvers  State  Hospital,  Massachusetts),  with  the  addition  of 
cultivations  from  mesenteric  lymph  nodes. 

2.  The  material  was  unselected,  save  (1)  that  cases  without 
readily  palpable  nodes  were  not  examined,  and  (2)  that  30  of 
the  50  cases  gave  macroscopic  signs  of  intestinal  disease  of  greater 
or  less  severity  (15  from  an  epidemic  of  bacillary  dysentery). 

3.  As  in  the  former  work,  there  were  no  detectable  differences 
in  the  proportion  of  bacteria  grown  at  different  intervals  post 
mortem.     (Table  I.) 

4.  Positive  cultivations  (excluding  a  few  frank  contaminations) 
were  obtained  in  (a)  cerebrospinal  fluid,  85  per  cent;  (6)  blood, 
80  per  cent,  and  (c)  node,  78  per  cent. 


81 

5.  Growths  from  all  three  regions  were  obtained  in  55  per 
cent. 

6.  Growths  from  two  out  of  the  three  regions  were  most  fre- 
quently obtained  in  cerebrospinal  fluid  and  lymph  node  (17  per 
cent),  a  fact  which  may  be  interpreted  as  due  to  an  effective 
bacteriolysis  in  the  blood  (compare  previous  article). 

7.  Table  II  gives  the  incidence  of  various  organisms  found: 
Cocci  in  the  blood,  20  cases;  in  the  cerebrospinal  fluid,  22  cases; 
and  in  the  lymph  node,  16  cases  (staphylococcus  aureus  in  these 
sources,  5,  6  and  3  cases,  respectively;  streptococci,  2,  1  and  0 
cases).     Bacilli  in- 1,  8  and  10  cases  in  the  respective  sources. 

8.  The  colibacilloses  are  especially  interesting  in  the  light  of 
the  relation  between  colibacillosis  and  "soft  brains"  suggested 
by  the  results  of  Gay  and  Southard.  Our  one  case  of  colibacil- 
lemia  failed  to  show  a  "soft  brain."  Two  of  three  cases  of  pure 
cerebrospinal  colibacillosis  yielded  "soft  brains,"  and  the  third 
(doubtful  bacteriologically)  was  negative.  The  three  combined 
lymphnodal  and  cerebrospinal  invasions  were  unsuitable,  being 
all  three  instances  of  extreme  sclerosis.  Two  of  the  3  pure 
lymphnodal  colibacilloses  showed  "soft  brains"  (one  only  in  non- 
sclerotic  parts)  and  the  third  was  negative.  Thus  4  out  of  7 
cases  suitable  for  such  display  showed  palpably  soft  brains  in 
association  with  colibacillosis. 

9.  Analyzing  in  the  other  direction,  there  were  7  "soft  brains" 
in  the  series,  3  of  which  showed  colibacillosis;  2,  infection  with 
special  pathogenic  bacilli  (under  special  study);  1,  contamination 
of  node;  and  1,  generalized  invasion  with  certain  unidentified  cocci. 

10.  Appropriate  atria  for  the  invasions  and  infections  are 
demonstrable  in  the  majority  of  instances. 

11.  Our  findings  seem  consistent  with  the  hypothesis  that  in 
the  terminal  exhaustions  of  the  insane  bacterial  invasions  are 
almost  the  rule.  Perhaps  otherwise  normal  and  quite  healthy 
subjects  may,  more  often  than  hitherto  suspected,  show  bacterie- 
mia  or  even  cerebrospinal  fluid  invasions. 

12.  The  intestinal  wall  is  a  leading  atrium  for  such  invasions, 
—  an  atrium  perhaps  the  more  penetrable  by  reason  of  atrophic 
processes  frequently  displayed.  The  livers  and  especially  the 
spleens  are  much  underweight  in  the  majority  of  our  cases. 

13.  Mesenteric  and  bronchial  lymph  nodes  lead  the  other  nodes 
in  proportion  of  diseases  displayed  in  the  total  Danvers  collection. 
Often  only  one  or  two  of  the  lymph  nodes  in  the  group  exhibited 
gross  lesions. 


82 

Southard,  E.  E.  A  Study  of  the  Dementia  Prsecox  Group  in  the 
Light  of  Certain  Cases  showing  Anomalies  or  Scleroses  in 
Particular  Brain  Regions.  American  Journal  of  Insanity, 
Baltimore,  1910-11,  LXVII,  119-176.  Also  in  Boston  Medi- 
cal and  Surgical  Journal,  1910,  CLXIII,  159-182. 

Conclusions. 

1.  Existent  evidence  for  the  organic  nature  of  dementia  prsecox 
is  not  wholly  convincing,  since  (a)  the  cytological  changes  de- 
scribed are  found  also  in  cases  of  toxic  deliria  and  in  cases  com- 
plicated by  severe  visceral  disease,  and  (b)  the  stratigraphic 
changes  described  are  found  also  in  certain  senile  cases  without 
characteristic  symptoms  of  dementia  prsecox. 

2.  Resort  must,  therefore,  be  had  to  the  topographic  idea,  for 
the  adequate  exploitation  of  which  total  brain  sections,  with 
cytological  exploration  of  all  areas,  are  ideally  necessary. 

3.  Random  blocks  of  brain  tissue  with  demonstration  of  satel- 
litosis,  infrastellate  gliosis,  or  disintegration  products  of  cell  dis- 
order will  throw  little  light  on  the  mechanism  of  dementia 
prsecox. 

4.  The  data  of  the  functionalists  (dissociation,  sejunction,  in- 
trapsychic ataxia,  and  the  like)  are  of  the  utmost  importance  as 
indicating  the  essential  focality  of  the  pathogenic  process  and  the 
focal  variations  in  its  severity. 

5.  The  curability  of  certain  cases,  the  remissive  character  of 
some  cases,  the  speedy  disappearance  of  particular  symptoms,  the 
persistent  complexity  of  reaction  in  some  instances,  the  absence 
of  characteristic  severe  projection-system  symptoms,  all  indicate 
that  the  process  is  histopathologically  mild,  and  that  the  focal 
changes  found  will  be  but  slightly  destructive  or  even  irritative 
(in  the  sense  of  slight  injuries  readily  repaired  or  compensated 
for). 

6.  Grossly  destructive  lesions  of  a  transcortical  character  in 
Wernicke's  sense  might  conceivably  effect,  e.g.,  a  permanent 
katatonic  complex,  and  doubtless  will  be  found  to  do  so  occasion- 
ally; but  the  protean  and  progressive  character  of  dementia 
prsecox  will  exclude  such  transcortical  injuries  from  playing  a 
large  part  in  the  pathogenesis. 

7.  The  focal  lesions  to  be  sought  for  will  doubtless  escape 
macroscopic  notice  in  many  instances,  since  the  volume  of  appa- 
ratus engaged  in  effecting  very  prominent  symptoms  is  often 
slight  and  spread  very  thin  in  numerous  areas. 


83 

8.  Studies  of  the  "soft  brain"  and  of  gliosis  in  epilepsy  have 
proved,  however,  that  even  comparatively  slight  degrees  of  corti- 
cal gliosis  can  often  be  palpated  at  autopsy. 

9.  Palpable  glioses  of  a  focal  or  variable  character,  combined 
in  numerous  instances  with  visible  atrophy  and  microgyria,  have 
been  found  in  over  half  the  series  under  examination,  in  cases 
regarded  as  clinically  above  reproach  and  not  subject  to  coarse 
wasting  processes,  focal  encephalomalacia,  cortical  arteriosclerosis, 
or  diffuse  chronic  pial  changes. 

10.  The  frequent  co-existence  of  several  foci  of  sclerosis  or 
atrophy  in  the  same  brain  and  the  microscopic  observation  of 
milder  degrees  of  nerve-cell  disorder  and  gliosis  in  regions  with- 
out gross  lesions  tend  to  the  conception  that  the  agent  is  more 
general  and  diffuse  in  its  action  than  would  seem  at  first  sight, 
so  that  future  research  may  well  demonstrate  that  certain  in- 
stances of  coarse  brain  wasting,  and  even  of  diffuse  chronic  lepto- 
meningitis, belong  in  the  group  (microscopic  corroboration  neces- 
sary for  assigning  values  to  focal  variations). 

11.  The  microscopic  examination  of  the  residue  of  cases  in 
which  gross  lesions  or  anomalies  were  not  described  shows  the 
same  tendency  to  gliosis  and  satellitosis  in  numerous  instances, 
and  the  same  tendency  to  focal  variations  from  gyrus  to  gyrus 
exhibited  by  the  gross  lesion  group.  These  findings  suggest  that 
the  minor  gross  lesions  and  anomalies  of  several  cases  actually 
escaped  notice  (the  protocols,  though  drawn  up  with  a  certain 
system,  are  by  various  hands)  at  autopsy,  so  that  the  probable 
actual  proportion  of  gross  lesions  is  68  per  cent.  If  microscopic 
evidence  is  resorted  to,  the  "organic"  proportion  in  our  series 
rises  to  86  per  cent. 

12.  Several  groups  of  cases  were  classified  from  the  distribu- 
tion of  macroscopic  lesions,  although  the  focal  purity  of  these 
cases  can  often  be  brought  in  question  from  the  results  of  micro- 
scopic examination  (infrastellate  gliosis  and  satellitosis  also  in 
macroscopically  "normal"  areas). 

(a)  Pre-Rolandic  group,  including  a  superior  frontal-prefrontal 
sub-group  of  paranoidal  trend  (c/.,  e.g.,  Case  1062). 

(b)  Post-Rolandic  group,  including  (a)  postcentral-superior- 
parietal  (sensory-perceptual)  sub-group  in  which  katatonic  fea- 
tures are  the  common  factors  (c/.,  e.g.,  Case  1298);  (b)  occipital 
sub-group  (c/.  Case  1149). 

(c)  Infra-sylvian    group    (too    small    for    clinical    correlations). 

(d)  Cerebellar  group  (katatonic  features). 


84 

13.  If  these  data  find  general  confirmation,  they  will  doubtless 
go  far  to  unify  discussion,  since  mild,  variable  and  progressive 
intracortical  lesions,  proceeding  at  different  rates  in  different 
parts  of  the  apparatus,  and  having  the  peculiar  distributions  in- 
dicated above,  would  explain  adequately  some  of  the  contentions 
of  the  dissociationists,  while  remaining  not  wholly  inconsistent 
with  Kraepelinian  ideas. 

14.  The  frontal-paranoid  correlation  is  in  line  with  modern 
physiological  ideas,  but  it  must  be  granted  that  the  occipital  and 
temporal  regions,  as  elaborating  important  long-distance  impulses, 
may  well  play  a  part  also  in  paranoid  states. 

15.  The  cerebellar-katatonic  correlation  is  doubtless  in  line 
with  some  contentions  of  the  Wernicke  school,  and  obvious  com- 
ments might  be  made  in  connection  with  the  proprioceptive  func- 
tions of  the  cerebellum  (Sherrington). 

16.  The  postcentral-superior-parietal  relations  to  katatonic 
symptoms  are  perhaps  theoretically  the  most  novel  suggestion 
from  the  work,  but  here  again  the  results  are  not  inconsistent 
with  modern  physiology. 

17.  The  topographic  study  of  dementia  prsecox  brains,  both 
gross  and  microscopic,  is  commended  as  likely  to  shed  new  light 
on  the  pathogenesis  of  certain  symptoms,  notably  paranoidal  and 
katatonic  symptoms. 

1912. 

Lucas,  W.  P.,  and  Southard,  E.  E.  Contributions  to  the 
Neurology  of  the  Child.  I.  Convulsive  Tendencies  during 
and  after  Encephalitis  in  Children.  (Reprinted  also  as 
Encephalitis  and  Epilepsy.)  Boston  Medical  and  Surgical 
Journal,   1912,   CLXVI,  323-328. 

Conclusions. 

1.  The  records  of  the  Children's  Hospital  from  1905  to  date 
have  been  searched  for  possible  instances  of  encephalitis.  Cases 
of  "encephalitis,"  "toxic  encephalitis,"  "meningitis(?),"  and 
"  (?),  encephalitis (?)"  have  been  considered. 

2.  Twelve  cases  have  been  chosen  which  may  with  some  reser- 
vations be  regarded  as  cases  of  encephalitis.  These  show  onset 
always  sudden.  Paralysis  or  paresis  in  all  cases  (oculomotor 
paralysis  in  7).  Deep  reflexes  altered  in  10.  Mental  symptoms 
in  10.  Rigidity  of  neck  in  9.  General  convulsions,  7  (absent  in 
4).    Nausea  or  vomiting,  5  (not  noted  in  7). 


85 

3.  The  results  fall  into  three  groups:  (a)  death  during  acute 
attack,  2  cases  (X  and  XI);  (b)  recovery  from  acute  attack, 
with  subsequent  epilepsy  and  mental  deficiency,  and  death  after 
twenty-one  months,  1  case  (II);  (c)  recovery  from  acute  attack, 
with  residual  symptoms,  5  cases  (I,  III,  V,  IX,  XII);  2  normal, 
except  for  strabismus  and  possible  slight  mental  change  (IV,  VI); 
2  epileptic  and  mentally  defective  (VII  and  VIII). 

4.  With  respect  to  epilepsy,  the  total  incidence  of  convulsions 
during  the  acute  attack  was  7  in  12.  Of  9  cases  still  living  5 
showed  convulsions  during  the  acute  attacks,  and  2  of  the  5 
(VII  and  VIII  in  chart)  are  epileptic. 

5.  In  both  epileptic  cases  there  was  a  brief  interval  between 
recovery  from  the  acute  attack  and  the  onset  of  epilepsy. 

6.  The  detailed  histories  of  a  case  developing  epilepsy  and  of  a 
fatal  case  with  autopsy  are  presented. 

Southard,  E.  E.  Psychopathology  and  Neuropathology:  The 
Problems  of  Teaching  and  Research  contrasted.  Journal  of 
American  Medical  Association,  Chicago,  1912,  LVIII,  914- 
916.  Also  in  American  Journal  of  Psychology,  1912,  XXIII, 
230-235. 

Southard,  E.  E.  Note  on  the  Geographical  Distribution  of 
Insanity  in  Massachusetts,  1901-10.  Boston  Medical  and 
Surgical  Journal,  1912,  CLXVI,  479-483. 

Summary  and  Conclusions. 

The  eugenic  area  or  areas  of  a  region  are  characterized  by  the 
operation  of  hereditary  factors  in  either  (a)  the  improvement  of 
the  contained  human  stocks,  or  (b)  the  maintenance  of  these 
stocks  in  statu  quo. 

The  aristogenic  program  is  that  extreme  eugenic  program 
which  seeks  to  produce  more  and  greater  great  men  for  the  world 
by  more  effective  mating. 

Against  an  ideal  aristogenic  program  are  operating  certain 
deteriorating  factors  of  hereditary  nature  (cacogenic  factors). 

The  data  immediately  available  in  Massachusetts  may  be  used 
in  the  study  of  eugenic  areas  in  the  second  or  negative  sense  (see 
(6)  above)  with  respect  to  insanity. 

The  morbidity  rate  of  the  Massachusetts  insane  commitments 
is  not  the  same  as  the  accumulation  rate,  as  an  effect  of  many 
combined  causes  (Owen  Copp's  data). 


86 

One  possibly  eugenic  area  exists  in  Massachusetts  in  three 
island  townships;  another,  in  nine  more  scattered  western  town- 
ships (seven  in  the  Berkshire  Hills  region). 

The  twelve  possibly  cacogenic  towns  have  produced  236  new 
cases  of  insanity  and  allied  conditions,  being  15  per  1,000  in  the 
population  of  these  towns  in  1910  (total  Massachusetts  rate,  7 
per  1,000);  highest  single  town  rate  considered,  19  per  1,000; 
Suffolk  County  (Boston,  etc.)  rate,  9  per  1,000;  highest  single 
city  rate,  10  per  1,000. 

These  possibly  cacogenic  townships  lie  chiefly  in  the  midland 
county  of  Worcester,  and  in  no  case  west  of  the  Connecticut 
River  or  on  the  seacoast. 

The  possibly  eugenic  and  possibly  cacogenic  towns  as  con- 
sidered from  the  commitment  standpoint  remain  so  to  a  degree 
when  considered  from  the  standpoint  of  the  census  of  the  same 
four  classes  enumerated  in  the  townships  May  1,  1905,  viz.,  2.6 
per  1,000  in  the  former,  to  3  per  1,000  in  the  latter,  group. 

A  more  striking  numerical  disparity  was  shown  by  the  census 
of  social  defectives  (prisoners,  juvenile  offenders,  paupers  and 
neglected  children)  May  1,  1905,  viz.,  8  per  1,000  in  the  eugenic 
group  against  20  per  1,000  in  the  cacogenic  group. 

The  population  of  the  eugenic  group  is  small  (2,945  in  1910) 
as  compared  with  that  of  the  cacogenic  group  (15,415  in  1910); 
the  eugenic  group  is  falling  somewhat,  the  cacogenic  group  rising 
somewhat,  in  general  population. 

The  nativity  of  the  general  population  in  the  two  groups 
differs  little,  —  830  per  1,000:840  per  1,000,  —  but  the  eugenic 
group  has  a  somewhat  higher  percentage  of  native-born  parents, 
and  a  still  higher  percentage  of  native-born  grandparents,  and 
may,  therefore,  represent  somewhat  stabler  stocks  than  the  caco- 
genic group. 

The  general  medical  and  social  picture  presented  by  the  census 
of  1905  is  distinctly  worse  for  the  cacogenic  group  than  for  the 
eugenic  group,  suggesting  that  the  insanities  and  allied  conditions 
are  apt  to  occur  in  a  background  of  more  general  diseases. 

If  we  assume  that  active  eugenic  measures  are  the  duty  of 
society  on  the  principles  of  self-preservation  or  of  self-improve- 
ment, then  such  measures  must  begin  somewhere.  The  present 
note  has  no  measures  to  propose,  but  merely  displays  certain 
concrete  social  differences  in  different  regions  of  Massachusetts. 
The  prevailing  laissez-faire  policy  cannot  safely  fall  back  on  the 
idea  that  all  the  stocks  are  "just  generally  degenerating,"  and 


87 

that  we  "should  not  know  where  to  begin."  I  should,  therefore, 
advocate  more  intensive  locality  studies  in  Massachusetts  as  well 
as  elsewhere,  and  the  collection  of  social  statistics  through  every 
public  and  private  channel  in  preparation  for  that  active  eugenic 
program  which  the  concrete  data  will  be  sure  to  indicate. 

If  there  be  a  statistical  correlation  between  insanity,  crime, 
pauperism  and  disease,  there  may  be  a  deeper  causal  relation 
between  some  of  these  factors. 

Southard,  E.  E.  The  Significance  of  a  Homoeopathic  Founda- 
tion for  Clinical  Research  and  Preventive  Medicine.  Boston 
Medical  and  Surgical  Journal,  1912,  CLXVI,  585-587. 

Southard,  E.  E.  The  New  Psychopathic  Department  of  the 
Boston  State  Hospital.  Boston  Medical  and  Surgical 
Journal,  1912,  CLXVI,  882-8.86. 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  Second  Note 
on  Bacterial  Invasion  of  the  Blood  and  the  Cerebrospinal 
Fluid  by  Way  of  Lymph  Nodes:  Findings  in  Bronchial  and 
Retroperitoneal  Lymph  Nodes.  Boston  Medical  and  Surgi- 
cal Journal,  1912,  CLXVII,  109-113. 

Summary. 

1.  Following  the  same  technic  adopted  by  Gay  and  Southard 
in  their  study  of  the  post-mortem  bacteriology  of  the  blood  and 
cerebrospinal  fluid  (100  cases),  and  that  of  Southard  and  Canavan 
in  their  study  of  the  blood,  cerebrospinal  fldid  and  mesenteric 
lymph  nodes  (50  cases),  the  writers  have  studied  the  post-mortem 
bacteriology  of  50  further  cases,  replacing  mesenteric  by  bron- 
chial lymph  nodes,  and  30  cases  adding  retroperitoneal  lymph  nodes. 

2.  The  conclusion  of  two  former  papers  is  further  established, 
viz.,  that  post-mortem  cultures  from  the  cerebrospinal  fluid  are 
more  likely  to  yield  growths  than  cultures  from  the  blood. 

3.  Just  as  the  cerebrospinal  fluid  proved  more  frequently 
positive  than  did  the  mesenteric  lymph  nodes,  so,  too,  the  fluid 
remains  more  frequently  positive  than  the  bronchial  lymph  nodes 
(nota  bene,  the  difficulty  of  taking  cultures  from  the  usually  small 
available  amount  of  lymph  node  material).  Retroperitoneal 
lymph  nodes,  however,  are  found  more  frequently  invaded  than 
either  blood  or  cerebrospinal  fluid  in  our  series.  The  84  per  cent 
positive  retroperitoneal  nodes   (1912)   are  only  exceeded  by  the 


88 

85  per  cent  positive  cerebrospinal  fluid  series  of  Southard  and 
Canavan  (1910). 

4.  Both  bronchial  and  retroperitoneal  lymph  nodes  exceed  the 
blood  in  frequency  of  positive  cultures;  the  excess  is,  however, 
slight. 

5.  The  most  frequent  two-out-of-three  positive  combination, 
found  in  1910,  was  the  combination  of  positive  cerebrospinal  fluid 
and  positive  mesenteric  lymph  node.  This  led  to  the  hypothesis  of  a 
lymphogenous  blood-borne  invasion  of  organisms  lodging  in  the  men- 
inges and  later  killed  out  in  the  blood  by  bacteriolytic  substances. 

6.  This  condition  is  reversed  in  the  present  series,  where  the 
combination  of  positive  cerebrospinal  fluid  and  positive  bronchial 
lymph  node  is  very  rare. 

7.  The  exceptional  nature  of  our  mesenteric  node  results  was 
suspected  when  they  were  obtained,  and  was  thought  to  depend 
somewhat  upon  the  selected  character  of  the  nodes  tested  (large, 
succulent  or  easily  palpable  nodes  were  chosen  for  culture,  and 
cases  without  such  nodes  omitted  from  the  series).  In  respect  to 
bronchial  and  retroperitoneal  nodes,  fewer  cases  had  to  be 
omitted  on  the  score  of  unavailable  nodes.  It  may  perhaps  be 
surmised,  then,  that  the  majority  of  bronchial  and  retroperi- 
toneal lymph  nodes  examined  were  executing  their  defensive 
duties  with  considerable  success,  and  were  not  letting  through 
great  numbers  of  organisms.  The  majority  of  mesenteric  nodes 
in  our  series  were  doubtless  reactive  to  unusual  conditions,  and 
were  permitting  more  organisms  to  get  through  the  lines. 

8.  The  retroperitoneal  nodes  are  on  a  different  footing  from  the 
bronchial  nodes  in  that  they  more  frequently  contain  organisms 
(84  per  cent  versus  64  per  cent).  The  combination  of  positive 
retroperitoneal  node  and  positive  cerebrospinal  fluid  is  the  most 
frequent  two-out-of-three  combination  (recalling  in  this  respect 
the  mesenteric  series) . 

9.  Positive  growth  from  all  three  loci  were  found  in  (a)  mesen- 
teric node  combination,  55  per  cent;  (b)  retroperitoneal  node 
combination,  52  per  cent;  (c)  bronchial  node  combination,  35 
per  cent. 

10.  These  combinations  of  growths  are  of  interest,  whether  one 
subscribes  to  the  intravital  or  to  the  post-mortal  invasion  theory, 
since  without  doubt  the  tissues  and  their  juices,  including  blood 
bacteriolysins,  remain  active  for  some  time  after  apparent  death. 

11.  Our  results,  as  before,  incline  us  to  the  idea  of  intravital 
significance  of  the  organisms  found.     The  statistics  show  similar 


89 

frequencies  early  and  late  post  mortem,  and  the  same  high  per- 
centages of  sterile  cultures  which  the  post-mortalist  finds  it  so 
hard  to  explain. 

12.  Tables  are  presented  showing  the  main  types  of  organism 
cultivated.  Special  remark  is  made  of  a  protracted  period  in 
which  an  anthrax-like  organism  kept  appearing  in  certain  autop- 
sies. The  question  of  ward  and  laboratory  epidemics  or  pseudo- 
epidemics  of  saprophyte  forms  is  brought  up. 

13.  On  the  basis  of  this  work  important  researches  into  in- 
travital conditions  can  be  imagined,  especially  in  the  field  of 
bacteriemia  and  "low-grade  sepsis." 

Southard,  E.  E.  Report  of  the  Mentality  of  a  Subject  fasting 
at  the  Nutrition  Laboratory  of  the  Carnegie  Institution  of 
Washington,  Boston,  Mass.,  from  April  14  to  May  15, 
1912.     (Privately  printed.) 

Remarks. 
In  brief,  therefore,  (1)  there  are  no  evidences  of  committable 
insanity  in  the  subject;  (2)  some  alienists  might  think  the  sub- 
ject a  psychopathic  personality,  but  (3)  the  subject  is  probably 
an  eccentric  and  not  a  psychopathic  person.  There  are  certain 
traces  of  psychic  exhibitionism  in  the  case.  No  erotic  origin  for 
this  phenomenon  was  discovered,  and  it  may  better  be  taken  on 
a  more  naive  basis  as  an  exaggeration  of  a  frequent  phenom- 
enon. The  egoism  was  rather  of  a  childish  character.  All 
signs  pointed  rather  to  vanity  than  to  ambition.  The  subject 
belongs  to  a  group  of  reformers  and  self-constituted  saviors,  and 
the  ultimate  decision  as-  to  his  character  must  depend  upon 
developments  of  psychiatric  theory  as  to  the  intellectual,  emo- 
tional and  volitional  significance  of  such  reform  tendencies. 
The  odds  at  present  favor  an  emotional  basis  for  these  tend- 
encies. 

1912-1913. 

Southard,  E.  E.  On  the  Somatic  Sources  of  Somatic  Delusions. 
Journal  of  Abnormal  Psychology,  Boston,  1912-13,  VII,  326- 
339. 

Summary. 
The  writer  has  sought  a  series  of  cases  of  delusion-formation 
in  which  the  false  beliefs  were  such  as  to  impute  structural  dis- 
order to  various   organs   (somatic   or  visceral  delusions).     Since 


90 

no  collection  of  correlations,  however  striking,  is  conclusive  in 
the  face  of  hosts  of  other  non-correlations  assumed  to  exist,  resort 
was  had  to  a  statistical  method.  In  a  series  of  1,000  autopsied 
cases,  some  38  cases  having  characteristic  somatic  delusions, 
and  not  showing  obvious  brain  lesions  at  autopsy,  were  found.  Of 
these  38,  8  were  found  which  were  fairly  free,  at  least  concerning 
the  correlations  at  issue,  from  complications  with  delusions  of 
other  types    (personal   or  social). 

In  these  8  cases  thus  impartially  drawn  a  statistical  correla- 
tion can  be  safely  stated  to  exist  between  such  "somatopsychic" 
or  severe  "hypochondriacal"  cases  and  serious  somatic  disease. 
It  seems  certain  that  these  serious  somatic  conditions  colored 
the  lives  of  the  patients. 

In  one  group  of  cases  (Cases  I,  II,  III,  possibly  VIII)  the 
psychic  rendering  of  the  somatic  states  is  rather  critical  and 
temporary,  and  follows  a  process  somewhat  comprehensible  to 
the  normal  mind.  (Type:  "Shot  by  a  fellow  with  a  seven- 
shooter,"  in  a  spot  found  to  correspond  with  a  patch  of  dry 
pleurisy.) 

In  others  (Cases  IV,  V)  the  psychic  rendering  is  less  natural 
and  is  more  a  genuine  transformation  of  the  sensorial  data  into 
ideas  quite  new.  (Type:  "Bees  in  the  skull"  found  in  the  case- 
with  cranial  osteomalacia.) 

In  others  (Cases  VI  and  VII)  the  problem  is  raised  whether 
severe  hypochondria,  with  ideas  concerning  dead  entrails  and  the 
like,  may  not  often  indicate  such  severe  somatic  disease  as 
tuberculosis.  The  psychic  rendering  here  is  of  a  more  general 
(apperceptive    (?))    sort. 

Hereditary  predispositions,  acquired  dispositions,  and  manifold 
unexplained  correlations  must  be  clearly  admitted.  The  concept 
of  the  crystallization  of  delusions  around  sensorial  data  of  an 
abnormal  sort  must  be  entertained  for  some  cases  at  least.  It 
would  not  be  safe  to  neglect  these  somatic  data  any  more  than 
it  would  be  well  to  neglect  the  patient's  turn  of  mind,  his 
critical  (though  perhaps  forgotten)  emotional  past  experiences, 
or  his  ancestry.  It  might  prove  that  the  results  of  careful 
physical  examination  would  have  much  to  do  with  the  diagnosis, 
or  even  the  prophylaxis,  of  certain  delusional  conditions. 


91 


1913. 

Southard,  E.  E.  A  Series  of  Normal-looking  Brains  in  Psycho- 
pathic Subjects.  Worcester  State  Hospital  Papers,  Con- 
tribution No.  11  (1912-13).  Also  in  American  Journal  of 
Insanity,  Baltimore,  1913,  LXIX,  689-704. 

Conclusions. 

1.  The  main  object  of  this  communication  is  to  stimulate 
interest  in  normal  or  normal-looking  brains  in  psychopathic  sub- 
jects, so  that  the  question  whether  insanity  is,  or  is  not,  always 
a  matter  of  structural  brain  disease  may  approach  settlement. 

2.  Normal-looking  brains  have  now  been  found  in  a  large 
fraction  of  senile  dementia  cases  in  two  autopsy  series,  so  that 
the  "functionality"  of  these  cases  stands  on  as  good  a  footing 
as  that  of  various  more  generally  recognized  "diseases  of  mental 
function." 

3.  The  issue  in  dementia  prsecox  is  now  clearly  defined,  since 
one  series  (Worcester)  might  be  interpreted  to  affirm  the  func- 
tionality, and  the  other  (Danvers)  to  affirm  the  structurally 
("organic  nature"),  of  the  disease  in  question. 

4.  Incidentally  the  question  has  arisen  whether  dementia 
prsecox  may  not,  on  the  ground  of  viability,  be  divided  into 
dementia  prcecox  brevis  (with  early  death,  say  under  two  years 
from  onset;  katatonic  form  often  here  found)  and  dementia 
prcecox  longa  (in  which  the  subject  dies,  as  a  rule,  more  than 
eight  years  after  onset,  of  a  variety  of  causes;  katatonic  form 
less  frequent). 

5.  Use  has  been  made  of  a  principle  that  apparent  normality 
of  brains  may  be  consistent  with  fine  microscopic  changes, 
possibly  of  a  reversible  nature,  and  that  we  shall  hardly  from 
gross  appearances  be  able  to  assert  abnormality  of  brains  unless 
at  least  three  months  (pre-indurative  period)  have  elapsed  from 
the  onset   of  some  cell-destructive  process. 

6.  Use  has  been  made  of  a  principle  to  the  effect  that  various 
nerve  cells  which  are  in  all  respects  intrinsically  normal  may  be 
essentially  sharing  in  processes  extrinsically  abnormal. 

7.  The  hypothesis  is  raised  that  the  whole  cortex,  or  even  the 
whole  nervous  system,  might  be  intrinsically  normal  but  extrinsi- 
cally abnormal  in  its  reactions  to  a  given  chemical,  physical  or 
other  condition. 


92 

8.  It  is  possible  that  the  solution  of  the  problem  of  the  func- 
tionality of  various  diseases  might  be  to  consider  the  structures 
involved  as  intrinsically  normal  whereas  extrinsically  abnormal — 
the  normal  operation  of  various  cells  leading  to  injurious  effects 
in  the  organism  as  a  whole. 

9.  It  seems  clear  that  the  general  statement  "insanity  is  brain 
disease"  is  well-nigh  meaningless  unless  the  particular  structures 
thought  to  be  involved  are  specified,  since  it  is  clear  that  science 
has  not  discovered  even  the  right  place  to  look  in  certain  diseases 
(no  more  in  mental  disease  than  in  certain  forms  of,  say,  dia- 
betes). 

Southard,  E.  E.,  and  Stearns,  A.  W.  How  far  is  the  Environ- 
ment responsible  for  Delusions?  Being  Danvers  State 
Hospital  Contribution  No.  38,  1913.  Journal  of  Abnormal 
Psychology,  Boston,  1913,  VIII,  117-130. 

Conclusions. 

By  choosing  cases  (from  a  group  of  1,000  cases  of  mental 
disease  autopsied  at  the  Danvers  State  Hospital)  on  these 
grounds  —  (a)  that  the  brains  were  normal  or  normal-looking, 
and  (b)  that  the  delusions  recorded  were  purely  or  almost  purely 
environmental  (allopsychic)  in  scope  —  we  have  arrived  at  a  small 
group  of  13  cases  suitable  for  analysis.  In  addition  to  these  13 
cases  there  were  18  others  (31  in  all)  which  had  been  listed  as 
almost  purely  allopsychic  in  scope;  but  of  these  18,  8  had  to  be 
excluded  as  probably  autopsychic  (intrapersonal)  in  essence,  3 
as  imbecile,  4  as  complicated  by  temperamental  faults,  and  3  as 
influenced  by  cranial  or  meningeal  disease. 

Of  the  13  more  truly  allopsychic  cases,  6  showed  close  correla- 
tion between  previous  history  and  contents  of  delusions,  but  the 
others  failed  to  show  such  correlation. 

The  problem  at  once  arises  whether  concealed  or  unknown 
personal  factors  may  not  have  had  much  to  do  with  these  seem- 
ingly pure  allopsychic  cases. 

Whether  delusions  often  spread  inwards  (egocentripetally)  or 
habitually  outwards  (egocentrifugally)  becomes  a  problem  to  be 
studied  along  these  same  statistical  lines. 

The  paucity  of  pulmonary  lesions  in  this  group  and  the  great 
frequency  of  cardiac  and  renal  lesions  suggest  further  problems 
of  a  more  difficult  nature. 


93 

Southard,  E.  E.  The  Outlook  for  Work  at  the  Psychopathic 
Hospital,  Boston,  1913.  Being  Psychopathic  Hospital  Con- 
tribution, 1913.14.  Boston  Medical  and  Surgical  Journal, 
1913,  CLXIX,  427,  428. 

Southard,  E.  E.  Mental  Disease  of  Somatic  but  Extra-nervous 
Origin  (Somatic  Psychoses).  White  and  Jelliffe's  Modern 
Treatise  of  Nervous  and  Mental  Disease,  Philadelphia  and 
New  York,  1913,  I,  518-528. 

Southard,  E.  E.    Contributions  from  the  Psychopathic  Hospital, 

•   Boston,    Mass:     Introductory    Note.      Being    Contribution 

from    the    Psychopathic    Hospital,    Boston,    Mass.,    No.    1 

(1913.1.)      Boston    Medical     and     Surgical    Journal,     1913, 

CLXIX,  109-116. 

Summary. 

The  contributions  of  a  psychopathic  hospital  like  the  new 
Boston  institution  are  likely  to  emanate  from  the  laboratory  and 
to  be  of  somatic  trend.  Their  source  will,  however,  be  the  pa- 
tients themselves,  since  many  psychiatric  problems  (e.g.,  those  of 
speech)  are  hardly  workable  in  lower  animals.  These  clinical 
problems  are  bound  to  be  of  a  wide  range  on  account  of  the  rep- 
resentativeness of  the  clinical  material,  —  the  drainage-product, 
namely,  of  a  metropolitan  district.  German  models  are  avail- 
able, and  articulation  with  the  State  system  of  government  car- 
ries with  it  sundry  advantages. 

The  juxtaposition  of  the  medical  and  social  points  of  view 
must  direct  our  progress.  Local  influences  (Massachusetts  Gen- 
eral Hospital,  Boston  Dispensary)  are  of  especial  advantage. 

We  are  not  so  happy  in  possessing  as  yet  few  competitors; 
nothjng  like  the  number  of  psychiatric  observers  (and  of  clinics 
for  such  observers)  can  soon  be  hoped  for  in  America  as  are  to  be 
found  in  German-speaking  countries. 

Juxtaposition  of  scientific  establishments  for  medical  research 
characterizes  the  recent  Boston  developments  in  which  the  medi- 
cal schools,  various  privately  endowed  institutions  and  the  Com- 
monwealth have  shared.  Various  examples  are  cited  in  the  text 
of  men  working  in  adjacent  institutions,  whose  work  should  be  a 
stimulus  to  ours. 

The  traditions  of  Massachusetts  in  psychiatry  are,  however,  by 


94 

no  means  negligible.  Examples  are  offered  in  the  text  of  men 
who  have  set  the  more  recent  traditions. 

A  rough  statistical  analysis  of  contributions  by  these  more  re- 
cent Massachusetts  worthies,  and  of  contributions  by  workers 
contributing  to  three  separate  sets  of  State  hospital  Festschrift 
papers,  serves  to  demonstrate  that  about  one-half  of  all  these 
contributions  have  dealt  with  matters  of  nerve  structure. 

The  paucity  of  sociological  and  psychological  contributions  is 
clearly  in  evidence.  To  secure  a  more  even  development  of 
psychiatry,  these  latter  should  be  stimulated,  though  naturally 
our  somatic  studies  should  not  be  permitted  to  lag.    . 

Ltjcas,  W.  P.,  and  Southard,  E.  E.  Contributions  to  the 
Neurology  of  the  Child.  III.  Further  Observations  upon 
Nervous  and  Mental  Sequelae  of  Encephalitis  in  Children. 
Boston  Medical  and  Surgical  Journal,  1913,  CLXIX,  341- 
345. 

Results. 
The  facts  elicited  are  surely  striking,  and  are  significant  in  the 
following  ways :  — 

1.  They  illustrate  the  importance  of  what  might  be  called 
sequence  studies. 

2.  A  further  study  has  brought  to  light  one  more  case  of 
epilepsy,  making  10  per  cent  of  our  present  total,  a  figure  not 
inconsistent  with  general  statistical  expectation. 

3.  On  the  same  general  statistical  grounds  we  might  have  pre- 
dicted that  our  number  of  mentally  backward  children  would 
increase  as  the  number  investigated  grew.  In  this  group  we  now 
have  five  children,  two  of  whom  are  feeble-minded  without  any 
signs  of  epilepsy,  and  three  are  cases  of  marked  mental  retarda- 
tion or  backwardness.  (Not  reaching  the  grade  of  feeble-minded- 
ness  —  imbecility  of  English  writers.)  This  gives  28.5  per  cent 
of  the  living  children  who  show  marked  mental  defects. 

4.  There  are  four  (or  15  per  cent)  of  these  cases  that  show  less 
marked  residual  effects  from  their  encephalitis,  (a)  either  by 
excessive  "nervousness"  or  (b)  because  they  show  a  much 
shorter  reaction  period  to  fatigue. 

5.  Two  (or  7.1  per  cent)  still  show  motor  sequela;  (strabismus). 

6.  There  are  28.5  per  cent  who  have  died. 

7.  Only  six  (or  21.5  per  cent)  of  the  children  show  no  signs  of 
their  previous  attack,  and  are  apparently  normal  in  every  way. 

8.  Tabulation  of  these  results  is  as  follows:  — 


95 

Epilepsy,  Nos.  7,  8,  13  or  10.7  per  cent,  or  7.1  per  cent  not  counting   13. 
Feeble-minded,  Nos.  5,  20  or  7.1  per  cent. 
Backward,  Nos.  6,  4,  28  or  10.7  per  cent. 
Nervous  or  easily  tired,  Nos.  15,  17,  31,  24  or  14.6  per  cent. 
Strabismus,  Nos.  1,  16  or  7.1  per  cent. 
Normal,  Nos.  9,  3,  18,  19,  22,  23  or  21.5  per  cent. 
Dead,  Nos.  2,  10,  11,  14,  25,  26,  27,  29  or  28.5  per  cent,  or  25  per  cent 
without  No.  2. 

28.5  per  cent  show  marked  mental  defect. 
50  per  cent  show  some  stigmata. 
21.5  per  cent  are  normal. 
28  per  cent  died. 

9.  These  results  impel  further  investigation  of  these  cases  and 
of  any  other  ones  we  may  have  occasion  to  follow  from  time  to 
time.  Our  first  endeavor  has  been  to  learn  the  dimensions  of 
this  problem  (compare  Lucas'  work  on  sequelae  of  syphilis1) 
rather  than  to  study  any  portion  of  it  intensively.  We  now  plan 
to  make  intensive  studies  on  the  cases  we  have  so  far  followed, 
and  to  individualize  these  more  general  conclusions. 

Southard,  E.  E.  Second  Note  on  the  Geographical  Distribu- 
tion of  Mental  Disease  in  Massachusetts,  1901-10.  The 
Insanity  Rates  of  the  Smaller  Cities.  Read  before  the 
Demographic  Section  of  the  Fifteenth  Congress  of  Hygiene 
and  Demography,  "Washington,  D.  C,  September,  1912  (to 
be  published  also  as  a  part  of  the  Transactions  of  the  Con- 
gress). The  work  is  a  sequel  of  work  on  "  The  Insanity 
Rates  of  Massachusetts  Towns,"  read  before  The  Eugenics 
Section  of  the  American  Breeders'  Association  at  its  Eighth 
-Annual  Meeting,  Washington,  D.  C,  December,  1911,  and 
published  as  "  Note  on  the  Geographical  Distribution  of  In- 
sanity in  Massachusetts,  1901-10,"  Boston  Medical  and  Sur- 
gical Journal,  March  28,  1912.  Boston  Medical  and  Surgical 
Journal,  1913,  CLXIX,  302-306.  Also  in  Transactions, 
Congress  of   Hygiene  and  Demography,   1912,  VI,  217-226. 

Conclusions. 
1.  As  from  the  towns,  so  also  from  the  cities  is  there  a  marked 
variation  in  the  number  of  insane  contributed  to  the  State  insti- 
tutions. 

1  Contributions  to  the  Neurology  of  the  Child.  II.  Note  on  the  Mortality,  and  the  Propor- 
tion of  Backward  Children,  in  a  Series  of  Congenital  Syphilis  followed  subsequent  to  Hospital 
Treatment ;  from  the  Out-Patient  Department  of  the  Children's  Hospital  and  the  Department 
of  Pediatrics,  Harvard  Medical  School,  by  William  Palmer  Lucas,  M.D. 


96 

2.  The  range  of  variation  is  far  smaller  for  the  cities  (3.5  for 
Chicopee  and  Pittsfield  to  9.8  from  Chelsea  per  1,000  inhabitants 
in  a  period  of  ten  years)  than  for  the  towns  (0  in  the  case  of  12 
towns  to  16.4  or  higher  in  other  towns). 

3.  The  treasury  of  the  Commonwealth  would  be  favorably  or 
unfavorably  affected  by  political  geography  as  follows:  Most 
favorable  to  the  treasury  would  be:  (1),  certain  rural  conditions 
where  the  apparent  Utopia  of  no  commitments  prevails;  next, 
(2),  the  conditions  of  certain  cities  (e.g.  Chicopee  and  Pittsfield) 
would  be  apparently  most  favorable,  unless  it  can  be  demon- 
strated that  special  commitment  habits  there  prevail,  favorable 
to  the  purse  directly,  but  indirectly  unfortunate  for  the  com- 
munity; (3)  more  likely  to  approach  the  community's  ideal  are 
the  conditions  of  the  suburbs  of  Boston,  which  seem  to  produce 
even  less  insane  than  (4)  the  towns  in  general,  which  are  ex- 
ceeded a  little  by  (5)  the  non-metropolitan  towns  of  the  State  at 
large;  (6)  the  cities  of  the  metropolitan  district  outside  Boston 
are  less  productive  of  commitments  than  (7)  the  average  for  the 
Commonwealth  as  a  whole;  or  (8),  that  for  all  cities;  (9),  the 
metropolitan  district  as  a  whole;  (10),  the  metropolitan  cities, 
including  Boston;  (11),  Boston;  (12),  Chelsea;  (13),  certain 
rural  conditions. 

4.  Accordingly,  it  is  safe  to  say  that  "rural  degeneracy"  is 
focal,  but  not  universal,  in  Massachusetts,  and  that,  on  the 
whole,  the  towns  are  better  off  than  the  cities  as  commitment 
producers. 

5.  Certain  cities  can  be  picked  out  as  proper  subjects  for  in- 
tensive study:  (a)  low-rate  cities,  Chicopee  and  Pittsfield,  must 
be  compared,  as  well  as  (&)  Lawrence  and  Waltham,  yielding  the 
Commonwealth's  average  rate;  (c)  all  seven  cities  having  a  rate 
lower  than  the  general  town  rate  should  be  studied;  (d),  Salem 
might  be  of  interest  as  having  the  average  rate  of  all  cities; 
(e),  Holyoke,  that  of  all  towns;  (/),  there  are  surprising  con- 
trasts in  the  output  of  various  seaports. 

6.  The  attempt  to  utilize  the  census  enumerations  of  (a)  social 
defectives  and  (6)  physical  defectives  as  correlative  with  the 
official  commitment  rates  is  fairly  successful,  and  yields  a  degree 
of  confidence  in  the  census  enumerators  (1905)  which  is  com- 
forting. 

7.  The  number  of  physical  defectives  found  living  May  1, 
1905,  used  as  exemplifying  conditions  in  the  decade,  is  found  to 
vary  up  and  down  with  the  insanity  rate  in  the  different  groups 


97 

of  cities;   the  number  of  social  defectives  appears  to  remain  more 
nearly  constant. 

8.  Comparison  of  the  towns  with  the  cities  seems  to  show  that, 
while  cities  are  committing  more  insane  than  towns,  they  harbor 
fewer  social  and  physical  defectives  than  the  towns.  This  may 
perhaps  mean  that  cities  have  more  effective  means  than  towns 
of  getting  rid  of  all  sorts  of  defectives.  If  this  be  the  case,  then 
we  may  permit  outselves  renewed  confidence  in  the  census  sta- 
tistics. 

9.  Another  suggestive  correlation  is  that  between  the  towns  in 
general  and  the  seven  low-rate  cities.  The  seven  cities  distin- 
guished by  low  commitment  rates  are  also  distinguished  by  low 
rates  of  surviving  social  and  physical  defectives,  and  the  latter 
rates  are  lower  than  those  of  cities  in  general. 

Southard,  E.  E.  Medical  Contributions  of  the  State  Board  of 
Insanity  of  Massachusetts:  Introductory  Note.  Contribu- 
tion of  the  State  Board  of  Insanity  of  Massachusetts  No.  1 
(1913.1).  Also  in  Boston  Medical  and  Surgical  Journal, 
1913,  CLXIX,  537-540. 

Summary  and  Remarks. 

A  general  picture  is  offered  of  the  medical  scientific  activities 
of  the  State  Board  of  Insanity  of  Massachusetts.  The  duty  of 
investigation  and  publication  as  prescribed  by  law,  and  the 
special  duties  of  the  pathologist  to  the  board,  are  summarized. 

A  general  summary  of  the  various  pieces  of  investigation  before 
and  after  the  special  appropriation  was  made  is  given.  It  is 
estimated  that  over  twenty-five  workers  have  contributed  to 
various  aspects  of  the  different  investigations.  The  investiga- 
tions are  listed  under  fourteen  heads,  of  which  eight  relate  to 
work  done  subsequent  to  the  special  appropriation. 

It  is  impossible  that  studies  of  this  particular  type  and  range 
shall  be  carried  out  without  special  funds,  such  as  the  New  York 
Lunacy  Commission  and  the  Massachusetts  Board  of  Insanity 
provide.  It  is  hoped  that  other  States  will  be  prevailed  on  to 
establish  a  similar  policy.  The  amount  of  money  necessary  for 
such  investigations  is  negligible  as  compared  with  the  money 
spent  on  maintenance;  'the  results,  however  insignificant  they 
may  appear  at  a  given  moment,  are  bound  to  be  some  day  of 
importance. 


98 

It  is  planned  in  future  to  publish  various  medical  contributions 
from  the  State  Board  of  Insanity  in  various  appropriate  journals 
with  serial  numbers  so  that  readers  may  readily  refer  back  to 
earlier  contributions. 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  Bacterial  In- 
vasion of  Blood  and  Cerebrospinal  Fluid  by  Way  of  Lymph 
Nodes,  Findings  in  Lymph  Nodes  draining  the  Pelvis.  Journal 
of  American  Medical  Association,  Chicago,  1913,  LXI,  1526- 
1528. 

Summary  and  Remarks. 

1.  The  continuation  of  our  former  works  shows  that  the  cere- 
brospinal fluid  (72  per  cent)  still  leads  the  heart's  blood  (68  per 
cent)  in  percentage  of  positive  cultures  (routine  aerobic  methods, 
post-mortem  material). 

2.  Pelvic  lymph  nodes  (like  mesenteric  nodes  in  our  former 
work)  lead  both  blood  and  spinal  fluid  (75  per  cent). 

3.  This  is  possibly  due  to  the  great  percentage  of  pelvic  lesions 
in  the  present  series  (20  out  of  25  cases;  15  of  the  20  showing 
organisms  in  pelvic  lymph  nodes). 

4.  It  is  still  uncertain  whether  these  findings  indicate  ante- 
mortem  or  post-mortem  invasions.  Of  course  an  acute  or 
chronic  lesion  may  conceivably  help  the  penetration  of  organisms 
from  without. 

5.  If  (as  seems  likely)  the  invasions  are  intravital  or  agonal, 
then  it  would  appear  that  the  pelvic  lymph  nodes  are  accustomed 
to  harboring  many  bacteria  (compare  the  mesenteric  lymph 
nodes  in  an  epidemic  of  dysentery). 

6.  Whether  this  habit  of  receiving  more  organisms  than  other 
nodes  induces  any  superiority  on  the  part  of  these  nodes  in 
respect  to  their  power  of  digestion  we  cannot  say.  If  so,  a 
rationale  for  Fowler's  drainage  position  (upper  part  of  abdomen 
maintained  higher  than  lower  part)  might  be  imagined.  Such 
a  rationale  would  be  superior  to  saying  that  the  pelvic  perito- 
neum is  a  better  filter  than  others,  or  is  differently  constructed 
from   peritoneum    elsewhere. 

7.  The  pelvis,  often  subject  to  acute  and  chronic  disease  in 
the  insane,  appears  to  supply  its  lymph  nodes  with  very  numer- 
ous bacteria  (both  motile  and  non-motile  and  of  many  groups). 
Some  of  these  are  saprophytes,  some  doubtless  pathogens;  they 
are   often   found   in   the   cerebrospinal   fluid   post   mortem,    even 


99 

when  absent  (destroyed  (?))  in  the  blood.  The  pelvis  compares, 
under  the  random  conditions  studied,  with  the  intestinal  tract 
in  its  habit  of  supplying  bacteria  to  regionary  lymph  nodes; 
and  perhaps  the  pelvis  surpasses  the  intestinal  tract,  since  the 
latter's  lymph  nodes  happened  to  be  studied  during  an  epidemic 
of  intestinal  disease  which  provided  an  excess  of  secondary 
invaders. 

8.  The  hypothesis  of  a  route  of  meningeal  invasion  by  way 
of  the  blood  receives  added  support  from  this  work,  although 
the  possibility  of  more  direct  invasion  must  be  considered. 

Southard,  E.  E.  On  Institutional  Requirements  for  Acute 
Alcoholic  Mental  Disease  in  the  Metropolitan  District  of 
Massachusetts  in  the  Light  of  Experiences  at  the  Psycho- 
pathic Hospital.  Being  Contribution  from  the  Psycho- 
pathic Hospital,  Boston,  Mass.,  No.  34  (1913.34).  Boston 
Medical  and  Surgical  Journal,  1913,  CLXIX,  937-942. 

Conclusions. 

Alcoholic  mental  disease  forms  at  present  about  one-ninth  of 
the  Psychopathic  Hospital's  work  (217  in  1,829  admissions  during 
sixteen  months).  Over  50  cases  of  delirium  tremens  have  been 
admitted  against  the  law  governing  these  matters,  either  on  the 
ground  of  common  humanity  or  because  of  errors  in  the  very 
difficult  differential  diagnosis  between  delirium  tremens  and  the 
more  protracted  disease  alcoholic  hallucinosis  (which  latter  is 
regarded  as  suitable  for  the  Psychopathic  Hospital).  A  number 
of  devices  have  been  adopted  at  the  hospital  to  minimize  this 
error  in  diagnosis  and  to  increase  our  knowledge  of  the  two 
conditions  (distinctive  between  "short"  and  "long"  cases 
(Stearns),  work  of  clinical  historian,  social  service,  and  eugenics 
worker,  the  Myerson-Eversole  pupil  reaction,  etc.). 

The  mortality  of  alcoholic  cases  at  the  Psychopathic  Hospital 
has  been  extremely  low  (about  5  per  cent).  The  mortality  in 
delirium  tremens  and  alcoholic  hallucinosis  is  virtually  nil  (0 
per  cent).  A  high  mortality  attended  our  Korsakow  cases  (about 
35  per  cent);    this  curious  fact  demands  a  special  investigation. 

These  results  are  superior  to  those  of  general  hospitals,  and 
this  superiority  we  attribute  to  our  methods  of  treatment,  chief 
among  which  we  place  hydrotherapy. 

The  moral  and  economic  value  of  saving  these  cases  needs  no 


100 

emphasis.  The  acutely  insane  are  now  accorded  in  most  com- 
munities better  treatment  than  are  drunkards  and  cases  of  de- 
lirium tremens,  despite  the  fact  that  the  latter  are  economically 
more  promising  in  the  light  of  after-care  results. 

A  hospital  for  acute  alcoholic  mental  disease  is  recommended 
for  the  metropolitan  district  as  a  first  step  to  the  proper  care 
of  these  cases  throughout  the  State.  Such  a  hospital  should,  in 
addition  to  its  high  medical  standards  (non-restraint,  non- 
drugging),  uphold  the  highest  social  standards  by  applying  in 
its  out-patient  department  the  now  well-established  principles 
of  after-care  for  alcoholics. 

Southard,  E.  E.  The  Psychopathic  Hospital  Idea.  Being 
Contribution  from  the  Psychopathic  Hospital,  1913.26. 
Journal  of  American  Medical  Association,  Chicago,  1913, 
LXI,  1972-74. 

Southard,  E.  E.,  and  Tepfer,  A.  S.  The  Possible  Correlation 
between  Delusions  and  Cortex  Lesions  in  General  Paresis. 
Journal  of  Abnormal  Psychology,  Boston,  1913-14,  VIII, 
259-275. 

Conclusions. 

1.  The  present  study  of  types  of  paranoia  in  general  paresis, 
coupled  with  a  former  study  of  the  sources  of  somatic  delusions 
in  a  series  of  subjects  with  relatively  normal  brains,  suggests  that 
somatic  delusions  lie  somewhat  apart  from  other  types  (auto- 
psychic,  allopsychic)  in  that  there  may  usually  be  found  for 
somatic  delusions  a  peripheral  basis  (organic  lesions  of  soma, 
lesion  of  receptor  paths,  lesion  of  central  receptive  apparatus 
of  cortex). 

2.  Accordingly,  the  diagnostician  will  proceed  with  unusual 
care  to  the  discerning  of  such  underlying  lesions,  although  the 
above  studies  abundantly  indicate  that  years  may  elapse  before 
such  lesions  are  manifest,  e.g.,   at  autopsy. 

3.  The  characteristic  delusions  of  general  paresis  (found  in 
57  per  cent  of  a  routine  series)  are  autopsychic. 

4.  The  distribution  of  gross  cortex-lesions  in  autopsychic  and 
non-autopsychic  cases  gives  some  color  to  the  hypothesis  that 
autopsychic  delusions  must  be  correlated  with  frontal  lobe 
lesions. 


101 

Southard,  E.  E.  Psychopathology  and  Neuropathology:  The 
Psychopathic  Hospital  as  Research  and  Teaching  Center. 
Being  Contribution  from  the  Psychopathic  Hospital,  Boston, 
Mass.,  No.  2  (1913.2).  Read  at  the  Conference  of  the 
National  Committee  on  Mental  Hygiene  at  the  College  of 
the  City  of  New  York,  Nov.  13,  1912.  Proceedings,  Mental 
Hygiene  Conference  and  Exhibit,  New  York,  1912,  137- 
146.  Also  in  Boston  Medical  and  Surgical  Journal,  1913, 
CLXIX,  151-154. 

Abstract. 
Theoretical  and  practical  objects  of  the  mental  hygiene  move- 
ment. That  movement  more  than  elaboration  of  the  obvious. 
Some  training  in  fundamental  medical  sciences  desirable  for  all 
educated  persons.  Supervision  by  schools  for  social  workers  of 
lay  workers  in  the  medical  field.  Lowering  the  age  of  graduation 
in  medicine  desirable  to  leave  time  for  a  little  research  before 
money-making.  Improvement  advocated  in  the  correlation  of 
studies  of  the  nervous  system  in  medical  schools.  Every  medical 
faculty  should  have  at  least  three  members  fundamentally  in- 
terested in  the  nervous  system.  Practical  work  in  psychiatry. 
Proper  medical  school  arrangements  for  psychiatry  greatly  de- 
pendent on  the  existence  of  a  psychopathic  hospital.  No  one 
model  possible  or  desirable.  The  new  Boston  arrangements. 
Branches  of  activity  of  the  Psychopathic  Hospital  in  Boston. 
Some  practical  conclusions  already  arrived  at  since  opening  the 
hospital  in  June,  1912.  Novel  conclusions:  importance  of  pedia- 
trics in  relation  to  psychopathic  hospital  work  (e.g.,  Lucas'  Boston 
Dispensary  Clinic  for  Adolescents),  possibility  of  prophylactic 
work  in  cases  on  older  hospital  records  as  having  had  nervous 
disease.     Research  should  be,  not  merely  permitted,  but  fostered. 

Southard,  E.  E.  What  Parts  of  the  Brain  does  Introspection 
reach?     (Abstract.)     Psychological  Bulletin,  1914,  XI,  66,  67. 

Southard,  E.  E.,  and  Bond,  E.  D.  Clinical  and  Anatomical 
Analysis  of  25  Cases  of  Mental  Disease  arising  in  the  Fifth 
Decade,  with  Remarks  on  the  Melancholia  Question  and 
Further  Observations  on  the  Distribution  of  Cortical  Pig- 
ments. Being  Danvers  State  Hospital  Contribution  No. 
40.  American  Journal  of  Insanity,  Baltimore,  1913-14, 
LXX,  779-828.  Also  in  Proceedings,  American  Medico- 
Psychological  Association,  1913,  265-314. 


102 


Summary  and  Conclusions. 
1    We  have  reviewed  a  group  of  25  cases  of  mental  disease 
(Danvers  State  Hospital  material),  so  selected  as  to  offer  a  fair 
sample  of  mental  diseases  arising  in  the  fifth  decade  of  life. 

2.  Our  principle  of  selection  excluded  all  cases  which  were 
obviously  not  characteristic  of  the  fifth  decade  (paresis,  alcoholic 
mental  disease,  and  the  like);  the  group  of  non-characteristic 
cases  thus  excluded  was  extremely  large  (approaching  80  per 
cent  of  all  cases  arising  in  the  decade),  and  the  preventable  dis- 
eases alone  amounted  to  over  60  per  cent. 

3.  We  remained  with  a  group  of  25  cases  (10  males  and  15 
females)  which  present  certain  common  aspects.  These  cases 
may  be  negatively  defined  as  not  due  to  syphilis,  alcohol,  cerebral 
arteriosclerosis,  brain  atrophy,  or  other  factors  yielding  coarse 
brain  disorder;  as  not  possessing  pronounced  schizophrenic  fea- 
tures; as  not  uniform  in  course  or  outcome;  as  not  likely  to 
show  either  elation  or  expansive  delusions.  They  may  be  posi- 
tively defined  as  almost,  if  not  quite,  constantly  subject  to  delu- 
sions at  some  stage  in  each  case;  as  yielding  manic-depressive 
traits  in  the  large  majority  of  cases;  as  prone  to  depressive  fea- 
tures; as  possessing  a  strong  hereditary  taint  (74  per  cent  of 
properly  studied  cases);  as  not  infrequently  suggesting  disorder 
of  glands  of  internal  secretion. 

4.  The  delusional  features,  present  in  all  cases  (save  one  of 
myxedema),  were  not  characteristically  of  any  particular  form; 
the  delusions  were  somatic  in  14  cases;  dealt  with  various  altera- 
tions of  personality  in  14  cases  (combined  with  somatic  delusions 
in  8  instances);  and  (superficially  at  least)  dealt  with  the  social 
environment  in  13  cases  (6  times  combined  with  other  forms). 

5.  As  to  somatic  delusions,  it  is  further  of  note  that  a  physical 
basis  could  be  recognized  for  many  of  them  in  diseases  of  the 
viscera;  and  that,  on  the  whole,  these  visceral  counterparts  of 
the  delusions  were  more  serious  than  the  patients'  complaints 
themselves. 

6.  Delusions  of  negation  (5  instances)  and  of  unreality  (4 
cases)  do  not  bulk  so  large  statistically  as  they  are  apt  to  in 
descriptions  of  so-called  involution-melancholia. 

7.  The  group,  taken  as  a  whole,  is  far  more  suggestive  of 
manic-depressive  insanity  than  of  dementia  prsecox  or  of  any 
other  form  of  mental  disease. 

8.  On  the  whole,  depression  is  the  most  common  manic-depres- 


103 

sive  feature  of  these  cases;  but  the  constant  occurrence  of  vari- 
ous delusions  alongside  the  depressive  emotions  makes  the  latter 
seem  far  from  "causeless,"  certainly  not  so  causeless  looking  as 
the  depressions  of  manic-depressive  insanity. 

9.  It  cannot  be  dogmatically  asserted,  but,  on  the  whole,  these 
patients  seem  more  dominated  by  various  ideas  and  by  various 
more  or  less  false  beliefs  than  are  the  manic-depressives  of  earlier 
decades,  and  are  perhaps  more  victims  of  intellectual  than  of 
emotional  or  volitional  disorder.  However,  this  may  be  more 
appearance  than  reality,  and  further  work  may  again  pull  the 
emotions,  and  particularly  the  depressive  emotions,  into  the 
genetic  foreground. 

10.  As  to  the  designation  "involution-melancholia"  for  these 
cases,  it  may  be  surmised  that  the  term  was  adopted  by  alienists 
having  unpleasant  delusions  at  least  as  much  in  mind  as  unpleas- 
ant mere  emotions.  Perhaps  it  is  unwise  to  seek  to  overthrow 
the  classical  term  before  more  intensive  work  has  been  done  on 
the  actual  relation  of  the  intellect  to  the  emotions  in  this  group. 
How  far,  then,  it  may  be  asked,  is  the  melancholia  of  involution 
merely  systematic  and  responsive  to  intellectual  conditions? 

11.  Since  Freud  has  claimed  a  sexual  basis  for  paranoia,  and 
even  perhaps  for  paranoic  states  falling  short  of  paranoia,  it  is 
fair  to  inquire  how  far  the  present  group  has  a  sexual  basis. 
Three  of  the  15  female  cases  in  our  series  harbored  rather  system- 
atic delusions  of  persecution,  and  all  three  systems  had  a  sexual 
tinge.  This  fact,  allocated  with  the  not  infrequent  tendency  to 
disorder  of  glands  of  internal  secretion  in  certain  cases,  ought  to 
provide  a  fruitful  field  for  psychoanalytic  hypotheses. 

12.  Hallucinations,  as  a  rule  auditory,  were  observed  in  some- 
thing like  60  to  70  per  cent  of  the  cases.  There  are  a  priori 
reasons  (Wernicke)  for  relating  these  with  the  unpleasant  delu- 
sions characteristic  of  the  group;  but  whether  the  false  beliefs 
irradiate  over  to  incite  the  hallucinations,  or  whether  the  hal- 
lucinosis is  a  prime  factor  in  producing  the  false  beliefs,  must 
remain  an  open  question.  Statistically  we  should  be  forced  to. 
favor  the  former  process. 

13.  The  post-mortem  data  throw  some  light  on  the  negative 
definition  of  our  group  (see  paragraph  3  supra).  There  appears 
to  be  little  or  no  evidence  that  the  metabolic  disorder,  if  there 
be  such  underlying  this  group,  tends  to  brain  wasting. 

14.  Our  study  of  the  distribution  of  certain  chemically  ill- 
defined  lipoids  (or  pigments,  as  we  have  called  them)  shows  that 


104 

age  plays  some  part  in  the  amount  of  deposits,  perhaps  more  in 
the  neuroglia  cells  than  in  the  nerve  cells,  and  least  of  all  in  the 
perivascular  phagocytes. 

15.  All  cases  living  three  years  or  more  after  onset  of  symp- 
toms show  more  or  less  marked  accumulations  of  pigment  in 
neuroglia  cells.  The  same  cases  show  a  greater  variability  in  the 
nerve-cell  accumulations.  Occasionally  such  a  three-year  or  over- 
three-year  case  will  show  a  negligible  amount  of  pigment  in 
perivascular  phagocytes. 

16.  These  pigment-findings  are  in  substantial  agreement  with 
those  of  Southard-Mitchell,  1908:  — 

(a)  "Perivascular  cell  pigmentation  almost  uniform  in  differ- 
ent areas  of  the  same  case."  The  present  series  presents  only 
two  instances  of  marked  variability  from  area  to  area. 

(b)  "  Neuroglia  cell  pigmentation  .  .  .  varies  more  or  less  di- 
rectly with  age."  Our  present  group  presents  more  variation 
than  did  the  former;  there  is,  however,  no  absolutely  negative 
case  over  forty-six  years  of  age. 

(c)  "Nerve-cell  pigmentation  is  not  a  function  of  age."  Two 
cases  of  fifty  years  or  more  showed  no  appreciable  amount  of 
pigment,  and  three  others  showed  but  slight  amounts.  The 
variations  in  amount  within  a  given  brain  are  more  striking  than 
the  variations  shown  by  the  neuroglia  cell  pigments. 

17.  That  these  three  loci  for  the  deposition  of  pigment  tend 
at  last  to  a  species  of  saturation  is  indicated  by  the  fact  that  the 
even  degrees  of  moderate  or  of  marked  pigment  deposit  in  all 
loci  begin  to  appear  in  the  later  years  of  life  (one  case  at  forty- 
nine  years,  one  at  fifty-six,  and  the  rest  from  fifty-nine  to 
seventy-five  years). 

18.  The  fresh  point  of  view  thus  obtained  for  the  problem  of 
involution-melancholia  by  our  study  of  fifth-decade  insanities  may 
be  stated  as  follows:  — 

Involution-melancholia  has  been  regarded  as  possibly  akin  to 
manic-depressive  insanity,  or  even  identical  therewith,  or  as 
possibly  something  quite  different.  Perhaps  the  majority  of  psy- 
chiatrists would  regard  it  as  a  disease  akin  to  manic-depressive 
insanity,  but  modified  by  climacteric  or  presenile  changes,  and 
distinguished  from  manic-depressive  insanity  by  the  peculiar 
tendency  to  depression  which  has  given  it  its  name.  The  novel 
feature  of  our  investigation  has  been  to  study  the  age-factor. 
We  have  studied  unselected  cases  arising  in  the  fifth  decade  of 
life,  excluding  all  coarse  organic  cases  of  brain  lesion.     Our  re- 


105 

sultant  group  is,  we  believe,  although  small,  otherwise  ideally 
representative  of  the  conditions  underlying  mental  disease  at  this 
age-level.  Our  group  includes  a  sufficient  number  of  the  familiar 
cases  of  involution-melancholia  as  well  as  cases  of  delusional  in- 
sanity without  melancholia.  The  striking  fact  is  that  the 
melancholia  cases  prove  also  delusional.  In  so  far  as  our  group  is 
representative  of  the  fifth  decade,  we  believe  that  the  essential 
psychopathia  involutionis  is  characterized  by  delusions;  that  in 
the  large  majority  of  cases  melancholia  is  a  feature  superadded 
to  the  delusions;  and  that  in  a  smaller  majority  of  cases  halluci- 
nosis also  occurs.  The  fact  that  melancholia  may  assert  itself  as 
the  most  prominent  symptom  in  the  clinical  foreground  fails  to 
controvert  the  possible  genetic  importance  of  the  delusions.  As 
to  the  cause  of  psychopathia  involutionis,  it  is  easy  to  invoke  the 
glands  of  internal  secretion;  and  of  their  disorder  there  is  actually 
some  sign  in  a  number  of  cases.  Whether  such  disorder  or  some 
unknown  factor  determines  the  overpigmentation  (lipoid  accumu- 
lations) in  the  cortex  above  noted,  and  whether  these  deposits 
have  a  direct  relation  to  the  symptoms,  must  rest  with  the  future. 

Southard,  E.  E.  The  Mind  Twist  and  Brain  Spot  Hypotheses 
in  Psychopathology  and  Neuropathology.  Being  Contri- 
bution from  the  Psychopathic  Hospital,  No.  42  (1914.8). 
Psychological  Bulletin,  Princeton,  N.  J.,  and  Lancaster,  Pa., 
April,  1914,  XI,  117-130. 

Summary. 

I  am  sure  that  some  of  the  dozen  or  more  separate  conceptions 
to  which  I  have  asked  attention  in  the  above  review  will  hardly 
carry  conviction  in  the  present  sketchy  form. 

1.  The  mind-twist  versus  brain  spot  hypotheses  have  nowhere 
been  discussed  in  extenso  (although  see  articles  on  "The  Prob- 
lems of  Teaching  and  Research  contrasted,  and  a  Study  of  the 
Dementia  Prsecox  Group,"  etc.,  mentioned  in  text),  and  I  am 
not  sure  that  the  distinction  will  strike  the  reader  as  more  than 
a  fresh  sample  of  psychophysical  parallelism.  Without  special 
title  to  a  viewpoint,  I  wish,  however,  to  say  that  personally 
neither  parallelism  nor  interactionism  seems  to  me  safe  ground, 
and  that  some  kind  of  identity  hypothesis  for  all  the  operations 
concerned  would  be  better  consonant  with  my  views.  One  thing 
will  be  clear  from  the  above  sketch,  viz.,  that  it  may  well  be 
possible  that  mental  operations  of  the  introspective  kind  are  not 


106 

correlatable  (in  any  sense)  with  a  good  part  of  the  operations  of 
the  cerebral  cortex. 

2.  The  definition  of  consciousness  as  equivalent  to  cognition  and 
compounds  of  cognition  leaves  the  non-cognitive  portions  of  the 
mind  (will  and  emotions)  only  capable  of  introspection  by  the 
kinesthetic  and  allied  sensorial  routes.  But  whether  the  above 
definition  is  correct  or  not,  it  is  at  least  clear  that  many  authors 
in  the  past  have  confused  the  issue  by  identifying  mind  with 
consciousness  at  a  stage  when  neither  concept  was  capable  of 
exact  statement. 

3.  The  pathological  evidences  which  have  absorbed  my  personal 
attention  have  led  me  to  a  re-emphasis  of  the  Flechsig  concept  of 
anterior  and  posterior  association  centers;  to  a  natural  correlation 
of  consciousness  and  the  entire  sensory  portion  of  the  mind  with 
activities  of  the  posterior  association  center;  and  to  a  similar 
correlation  of  non-conscious,  i.e.,  objectivistic  or  behavioristic 
portions  of  the  mind  (notably  the  voluntary  faculties)  with 
activities  of  the  anterior  association  center.  The  prepallium 
(pre-Rolandic  cortex)  would  thus  be  more  closely  related  with 
behavior  (kinetic  and  pragmatic  schemata),  and  the  postpallium 
(post-Rolandic  and  infra-Sylvian  cortex)  most  closely  related 
with  consciousness. 

4.  But  if  the  prepallium  is  more  an  organ  of  behavior  than  the 
receiving  postpallial  mechanism,  it  is  expressly  to  be  stated  that 
the  capacity  for  novelty  production,  or  innovating  power,  is  not 
to  be  abstracted  from  the  prepallial  neurones.  Such  innovating 
power,  exquisitely  mental  as  it  seems,  is  not  necessarily  conscious 
in  the  sense  of  essentially  cognizable.  It  is  perhaps  only  the 
history  of  our  innovations  and  inhibitions  which  we  register  in 
the  postpallial  mechanisms.  Arguments  in  this  direction  are  to 
be  drawn  from  the  decisive  ruin  of  the  personality  which  attends 
prepallial  destructive  processes  in  general  paresis  of  the  insane. 

5.  A  sketch  is  offered  to  show  that  the  non-conscious,  i.e., 
non-cognitive,  side  of  delusion-formation  is  perhaps  more  im- 
portant than  the  conscious  (or  contentwise)  side.  At  least,  the 
morbid  correlates  of  delusion-formation  seem  to  be  prepallial 
rather  than  postpallial  disorder  as  a  rule. 

6.  The  reverse  seems  to  hold  for  such  apparently  motor  or 
behavior  phenomena  as  epileptic  and  cataleptic  phenomena. 
These  are  possibly  based  more  often  on  postpallial  (sensorial  (?), 
kinaesthetic(?))  disorder  than  on  intrinsic  disorder  of  behavior 
mechanisms. 


107 

Southard,  E.  E.  Eugenics  v.  Cacogenics:  An  Ethical  Question. 
Being  Contribution  from  State  Board  of  Insanity,  Boston, 
Mass.,  No.  21  (1914.1).  Journal  of  Heredity,  Washington, 
D.  C,  September,  1914,  V,  408,  414. 

Summary. 

1.  The  eugenics  propaganda  presents  ethical  difficulty  in  view 
of  our  ignorance  not  merely  how  to  breed  better  men,  but 
actually  what  improvement  or  improvements  we  seek. 

2.  The  plant  and  animal  breeders  know  what  they  are  breed- 
ing towards,  and  hence  face  problems  of  technique  only;  the 
eugenist,  it  may  be  feared,  does  not  know  to  what  he  ought  to 
breed  (unless  we  are  content  with  generalities  like  "citizenship" 
or  "brain-power"). 

3.  The  British  origin  and  historical  setting  of  the  eugenics 
movement  suggests  that  eugenics  is  an  outcome  in  one  sense  of 
British  utilitarianism,  although  there  are  certainly  no  Malthusian 
or  race-suicide  components  in  the  theory. 

4.  The  chances  are  that  the  ethical  basis  of  eugenics  lies  more 
in  the  evolutionistic  than  in  any  utilitarian  doctrines,  and  that, 
just  as  an  ethics  of  self -development  is  superior  to  an  ethics  of 
happiness-seeking,  so  an  ethics  of  race-development  is  superior 
to .  an  ethics  of  the  greatest  good  to  the  greatest  number  (at 
least  if  good  be  defined  as  anything  short  of  full  development). 

5.  At  all  events,  the  warning  deserves  utterance  that  no  narrow 
nationalistic  or  chauvinistic  interpretation  of  the  eugenic  aim 
should  be  allowed  to  prevail,  as,  for  example,  that  British  eugen- 
ics is  German  cacogenics  and  vice  versa.  The  eugenic  evolution 
should  rather  be  to  develop  each  nation  to  the  death-point  of 
national  prejudice  and  to  the  maximal  vitality  of  co-operation. 

6.  To  clarify  this  ethical  situation,  certain  distinctions  need  to 
be  drawn.  Both  in  the  matter  of  eugenics  and  in  that  of  caco- 
genics it  is  proper  to  distinguish  a  relative  from  an  absolute 
form. 

7.  Thus  the  breeder  of  draught-horses  might  consider  speed- 
producing  factors  as  interfering  with  his  plans,  as  relatively 
cacogenic,  whereas  he  might  well  acknowledge  that  another 
breeder  would  find  such  factors  relatively  eugenic  and  draught- 
horse  factors  relatively  cacogenic.  Similarly,  should  the  white 
race  go  down  in  its  heredity,  Caucasian  cacogenics  might  prove 
Semitic  or  Ethiopian  eugenics,  but  always  in  the  relative  sense 
of  these  terms. 


108 

8.  It  would  accordingly  be  wiser  to  consider  the  problem  of 
eugenics  in  the  absolute  sense  within  the  species.  Cacogenic 
factors  in  human  progress  would  not  be  merely  factors  which  for 
arbitrary  reasons  are  considered  proper  to  exclude,  as,  for 
example,  short  men,  with  prognathous  jaws,  etc.:  for  here  the 
cacogenics  would  be  merely  relative. 

9.  What  we  must  study  to  avoid  are  the  absolutely  cacogenic 
factors,  such  as  pathology  in  its  widest  sense  might  discover. 
Examples  of  such  absolutely  cacogenic  factors  are: — 

(a)  Possible  senescence  not  in  somatic  cells  only,  but  in  the 
germ-plasm  itself. 

(6)  Possible  prepotently  toxic  powers  in  a  gamete,  such  that 
all  zygotes  in  which  such  gamete  was  a  component  would  pro- 
duce morbid  individuals  out  of  all  theoretical  proportions. 

(c)  Possible  inheritance  of  qualities  acquired,  not  by  the 
somatic  cells,  but  by  the  germ-plasm  (e.g.,  through  alcoholism, 
syphilis). 

10.  This  contrast  between  relative  cacogenics  and  absolute 
cacogenics  reminds  one  of  the  contrast  between  the  pathology 
of  measurements  and  anomalies  and  the  pathology  of  survival- 
values  for  cells,  organs  and  the  organism. 

11.  It  may  well  be  that  the  pathology  of  survival-values  is 
theoretically  reducible  to  a  metric  basis,  and  that  these  survival- 
values  can  be  put  on  a  " more-or-less "  rather  than  on  an  "all- 
or-nothing"  basis.  There  is,  nevertheless,  an  important  sense 
in  which  the  pathology  of  anomalies  is  distinct  from  that  of  life 
and  death. 

12.  Accordingly,  I  propose  that  the  logical  technique  of 
pathology  be  applied  to  the  problems  of  absolute  cacogenics, 
such  problems  as  those  mentioned  in  paragraph  9  above,  to  the 
end  that  more  may  be  understood  as  to  the  essential  pathology 
of  the  germ-plasm. 

Southaed,  E.  E.  Statistical  Notes  on  a  Series  of  6,000  Wasser- 
mann  Tests  for  Syphilis  performed  in  the  Harvard  Neuro- 
pathological  Testing  Laboratory,  1913.  Boston  Medical  and 
Surgical  Journal,  1914,  CLXX,  947-950. 

Summary. 
1.  On   account   of  the   varying   standards   and   criteria   which 
have  held  or  will  in  future  hold  in  the  matter  of  Wassermann 
tests  for  syphilis,   it   has  been   thought   wise  to  summarize  the 


109 

materials,  controls  and  special  precautions  used  in  the  Harvard 
Testing  Laboratory. 

2.  General  doubts  are  often  raised  as  to  the  reliability  of 
Wassermann's  test  on  account  of  the  "great  number"  of  "doubt- 
ful" reactions.  This  "great  number"  resolves  in  our  large  series 
to  4  per  cent  of  the  blood  sera  and  2  per  cent  of  the  cerebro- 
spinal fluids. 

3.  On  statistical  grounds  we  find  the  "doubtfuls"  resolve 
much  more  frequently  into  "negatives"  than  into  "positives." 

4.  Twenty-three  per  cent  of  all  sera  examined  were  positive, 
and  since  the  cases  are  in  many  instances  picked  as  likely  to  be 
positive,  this  percentage  is  doubtless  much  higher  than  the 
community's  total  percentage. 

5.  Thirty-three  per  cent  of  all  cerebrospinal  fluids  examined 
were  positive.  The  principle  of  selection  of  these  cases  was  such 
(positive  serum  or  symptoms  of  "organic"  nervous  or  mental 
disease)  that  the  result  is  of  practical  value,  stateable  as  fol- 
lows: The  chances  of  a  syphilitic  origin  for  a  case  of  "organic- 
looking"  nervous  or  mental  disease  are  not  more  than  1  in  3. 

6.  The  Massachusetts  Reformatory  for  Women  yields  44  per 
cent,  a  partial  index  of  the  infected  nature,  though  not  neces- 
sarily of  the  «infectivity,  of  prostitutes  and  other  delinquent 
women. 

7.  The  Danvers  State  Hospital  (for  the  insane)  yields  between 
19  and  22  per  cent  positive  sera  in  its  routine  intake  of  cases 
from  Essex  County. 

8.  The  Worcester  Asylum,  a  transfer  institution  (to  which  are 
transferred  chiefly  Mcm-paretic  cases),  yields  less  than  3  per  cent 
positive.  If  this  percentage  should  be  maintained  in  future  work, 
one  might  infer  that,  from  the  group  of  persons  in  the  com- 
munity with  insane  tendencies  and  infected  by  syphilis,  cases  are 
drained  off  into  the  frankly  paretic  group,  in  such  wise  that  a 
population  of  asylum  transfers  will  be  likely  to  show  a  low  syphilis 
index.  But  this  conclusion  can  be  only  tentative  on  account  of 
many  other  issues. 

9.  The  Psychopathic  Hospital  index  (15  per  cent)  is  perhaps 
somewhat  closer  to  the  general  community  index  than  the  others 
just  mentioned  on  account  of  the  large  number  of  cases  "not 
insane"  that  are  tested,  but  it  is  evident  that  15  per  cent  would 
be  too  high  an  index  to  assign  to  the  syphilis  of  the  general  popu- 
lation. 

10.  Aside  from   its   capacity   to   solve   problems   of  individual 


110 

diagnosis,  the  Wassermann  method  is  obviously  of  such  value  to 
the  community  that  a  community  Wassermann  service  might  well 
be  undertaken  by  a  State  agency  such  as  the  Board  of  Insanity  or 
the  Board  of  Health. 

Southard,  E.  E.  Feeble-mindedness  as  a  Leading  Social 
Problem.  Being  Contribution  from  the  Psychopathic 
Hospital,  Boston,  Mass.,  No.  38  (1914.4).  Boston  Medical 
and  Surgical  Journal,  May  21,  1914,  CLXX,  781-784. 

Summary. 
I  will  sum  up  and  conclude  as  follows:  — 

1.  The  status  of  the  feeble-minded  in  Massachusetts  is  such 
as  to  offer  a  large  and  immediate  practical  problem. 

2.  The  availability  of  Binet-Simon  and  other  intellectual  tests 
makes  desirable  the  establishment  of  numerous  dispensary  centers 
for  preliminary  diagnosis,  so  that  cases  suitable  for  well-tried 
educational  methods  in  our  State  schools  may  be  winnowed  out. 

3.  The  criminalistic  group  has  been  singled  out,  hardly  so  far 
as  a  problem  of  the  present,  but  as  a  problem  of  the  future,  de- 
pendent for  solution  on  psychological  data  not  yet  available. 

4.  Estimates  of  the  numerical  size  of  the  problem  are  available, 
and  a  promising  preliminary  survey  is  being  made  by  the  Board 
of  Insanity. 

5.  Social  sense  of  the  importance  of  the  problem  has  been 
aroused,  though  not,  it  may  be  hoped,  to  the  point  of  impatience 
with  the  degree  of  progress  humanly  possible. 

6.  The  interest  of  specialists  in  children's  diseases  has  also 
been  aroused,  and  the  eventual  results  of  certain  children's 
diseases  are  being  shown  in  the  concrete  case. 

7.  Workers  in  eugenics  are  being  enlisted  to  study  the  heredi- 
tary factor  in  some  of  these  so-called  "acquired"  cases,  and,  it 
is  hoped,  will  solve  the  problem  of  the  interplay  of  heredity  and 
somatic  factors  in  the  pathology  of  feeble-mindedness. 

8.  Statistical  inquiries  seem  to  justify  the  idea  of  a  chiaro- 
scuro of  distribution,  which  means  that  society  is  not  just  gen- 
erally degenerating,  and  that  the  places  to  begin  preventive  work 
can  be  chosen  scientifically. 

9.  Statistics  tend  to  indicate  that  the  problem  is  rather  a 
medical  than  an  economic  one,  or,  perhaps  better,  more  medical 
than  economic,  standing  a  bit  one  side  perhaps  from  crime,  some 
part  of  which  is  economic. 


Ill 

10.  The  interplay  of  hereditary  and  somatic  factors  promises 
to  show  lines  of  prevention  both  eugenic  and  environmental. 

11.  We  can  educate  communities  in  eugenics  and  we  can  con- 
ceivably transplant,  by  a  proper  family-care  system,  feeble- 
minded persons  from  neighborhoods  where  they  would  unite  with 
others  of  their  kind  to  regions  where  they  would  either  not  marry 
or  would  marry  normal  persons,  thus  diluting  the  strain  (feeble- 
minded males  are  probably  less  dangerous  in  the  community 
than  feeble-minded  females,  which  latter  should  be  segregated  by 
preference  in  institutions). 

12.  Socialism  of  the  Fourier-Marx  type  will  have  to  reckon 
with  this  problem;  it  would  not  appear  that  communism  has  any 
ready  solution  for  the  problem  of  those  who,  being  feeble-minded, 
are  by  nature  neither  free  nor  equal.  On  the  other  hand,  some 
form  of  socialism  of  the  St.  Simon  type,  or  what  may  be  termed 
state  socialism,  is  the  most  practicable  form  to  cope  with  this 
problem.  Indeed  the  practical  solution  of  these  problems  of 
feeble-mindedness  and  allied  defects  is  fast  leading  us  to  some- 
thing of  the  sort,  whether  we  choose  to  call  it  socialism  or  not. 
Yet  how  many  vvould-be  socialists  face  the  congenital  or  acquired 
inequalities  of  men  with  frankness  and  clear  understanding? 

Southard,  E.  E.  Considerations  bearing  on  the  Seat  of  Con- 
sciousness. (Abstract.)  Journal  of  Nervous  and  Mental 
Disease,  New  York,  1914,  XLI,  581. 

Abstract  only. 
The  reader  attempts  to  correlate  consciousness  with  the 
posterior  association-center  of  Flechsig,  and  possibly  rather  more 
intimately  with  that  of  the  right  cerebral  hemisphere.  The 
reader  views  consciousness  as  a  much  narrower  term  than  mind, 
and,  if  the  term  mind  is  to  include  knowing,  feeling  and  willing, 
finds  consciousness  rather  cognitive  than  affective  or  volitional, 
and  believes  that  will  and  emotions  appear  to  consciousness 
rather  in  a  cognitive  (kinesthetic)  aspect  than  in  any  more  pro- 
found or  elementary  manner.  To  put  the  matter  concretely,  the 
reader  questions  whether  it  is  necessary  to  suppose  ideas  of  words 
correlated  in  any  sense  whatever  with  operations  of  Broca's  area. 
Broca's  area  contains,  rather,  the  necessary  kinetic  schemata  of 
words.  Generalizing  therefrom,  the  reader  wonders  whether  any 
ideas  either  occupy  or  are  in  any  sense  correlated  with  activities 
of    the    anterior    association-center,    which    contains,    rather,    the 


112 

various  kinetic  and  pragmatic  schemata  that  underlie  voluntary 
action  and  conduct.  Data  from  comparative  anatomy  and  from 
casualty  wards  are  advanced  in  support  of  this  conception. 

Southard,  E.  E.  Conclusions  from  Work  on  the  Paratyphoid 
Epidemic  at  the  Boston  State  Hospital,  1910.  Boston  Medi- 
cal and  Surgical  Journal,  1914,  CLXXI,  556-559. 

General  Conclusions. 

The  epidemic  of  mild  paratyphoid  fever  at  Boston  State  Hos- 
pital in  1910  seems  beyond  question  due  to  Bacillus  paraty- 
phosus,  alpha  (findings  of  Richards).1 

Apparently  the  source  of  the  epidemic  was  infected  meat,  or 
else  a  patient  with  paratyphoid  infection  may  have  spread  the 
epidemic  through  meat.  The  clinical  features  of  the  epidemic  of 
greatest  interest  are  presented  in  parallel  columns.  Mention 
may  be  here  made  of  the  fact  that  initial  fever  was  practically 
constant.  Anorexia,  diarrhea,  abdominal  pain,  general  malaise 
and  vomiting  were  not  so  frequent  in  this  paratyphoid  epidemic 
as  they  usually  are  in  typhoid  fever.  Of  special  modes  of  onset 
which  might  be  confusing  in  diagnosis,  bronchitis  may  be  men- 
tioned. In  the  course  of  the  disease  stiff  joints  occurred  in  19  of 
30  cases  of  paratyphoid  fever,  whereas  in  typhoid  fever,  arthritis 
is  rare.  Four  of  the  patients  suffered  from  muscle  pains  in  the 
back  of  the  neck.  Malaria  was  suspected  in  one  case  from  the 
nature  of  the  acute  symptoms. 

A  case  is  presented  which  died  some  years  after  the  epidemic 
and  showed  thickening  of  the  ileum,  possibly  representative  of 
former  intestinal  disease,  but  whose  cultures,  including  that  of 
the  gall  bladder,  failed  to  show  bacillus  paratyphosus. 

The  clinical  picture  shows  points  of  interest  in  the  temperature 
curves.  A  case  will  occasionally  have  a  beginning  temperature 
suggestive  of  typhoid  fever,  but  this  is  not  the  rule.  The  inter- 
current bronchitis  fails  to  affect  the  temperature  reaction,  so  that 
it  may  possibly  be  supposed  that  it  is  a  portion  of  the  disease 
rather  than  a  truly  intercurrent  phenomenon.  But  it  must  be 
remembered  that  insane  patients  show  some  differences  in  fever 
reactions  to  various  infections  from  the  reactions  shown  by  sane 
persons. 

Eight  cases  in  30  showed  a  peculiar  drop  of  temperature  to 

1  E.  T.  F.  Richards:    Bacteriology  of  Epidemic  of  Paratyphoid  Fever,  Journal  Lancet,  St. 
Paul,  1913. 


113 

subnormal  in  the  second  or  third  week  —  as  a  rule,  between  the 
tenth  and  fourteenth  day.  This  temperature  drop  is  accom- 
panied by  a  drop  in  the  pulse  and  by  an  access  of  the  most 
severe  subjective  symptoms  felt  at  any  time  in  the  disease. 

The  blood  cell  pictures  show  that  there  is  no  hypoleucocytosis 
or  loss  or  drop  in  eosinophiles  in  paratyphoid  fever  (of  the  type 
here  described),  since  the  counts  remain  within  the  normal  range; 
this  point  may  be  of  some  value  in  differentiation  of  paratyphoid 
fever  from  typhoid  fever. 

It  was  incidentally  learned  that  the  blood  cell  picture  after 
antityphoid  vaccination  also  failed  to  show  hypoleucocytosis, 
but  instead  tends  to  show  a  slight  initial  rise  in  leucocytes. 

The  antityphoid  fever  vaccinations,  carried  out  early  in  the 
epidemic  as  a  possible  protective  measure,  gave  the  opportunity 
for  a  few  observations  on  the  relation  of  paratyphoid  fever  to 
antityphoid  vaccinations,  and  it  would  appear  that  there  may  be 
a  moderate  degree  of  crossed  protection  (typhoid  vaccine  against 
paratyphoid  fever),  since  non-vaccinated  persons  were  far  more 
subject  to  paratyphoid  fever  than  were  persons  vaccinated  against 
typhoid.    The  rule  was,  however,  not  absolute. 

Southard,  E.  E.  The  Association  of  Various  Hyperkinetic 
Symptoms  with  Partial  Lesions  of  the  Optic  Thalamus. 
Journal  of  Nervous  and  Mental  Disease,  New  York,  1914, 
XLI,  617-639. 

Summary. 
To  sum  up,  the  writer  has  made  an  orientation  study  of  the 
symptomatology  of  a  group  of  25  cases  of  chronic  diffuse  optic 
thalamus  lesion,  and  observed  96  per  cent  to  show  one  or  more 
symptoms  of  the  hyperkinetic  group  (exaltation,  irritability,  psy- 
chomotor excitement,  homicidal  tendencies,  destructiveness)  and 
but  40  per  cent  to  show  depressive  symptoms  (including  suicidal 
tendencies  and  apprehensiveness).  To  compare  with  these 
figures  the  writer  studied  the  symptomatology  of  261  cases  hav- 
ing normal  or  normal-looking  brains,  and  therein  found  only  64 
per  cent  showing  hyperkinetic  symptoms  and  52  per  cent  show- 
ing depressive  and  allied  symptoms.  The  one  exception  to  the 
thalamic  correlation  with  hyperkinesis  is  hardly  a  fair  exception, 
being  a  stuporous  general  paretic. 

In  evaluating  these  surprising  results,  it  must  be  remembered 
that  coarse  destructive  lesions,  destroying  through-routes  for 
sensory  impulses,  have  been  omitted  from  consideration,  and  that 


114 

two  additional  cases  of  chronic  diffuse  lesions  of  the  thalamus 
failed  to  yield  hyperkinesis  apparently  because  of  injury  to  the 
thalamocortical  system  above  them. 

The  hyperkinetic  symptoms  are  on  theoretical  grounds  pos- 
sibly due  to  withdrawal  of  corticothalamic  "inhibitory"  or 
"switch-setting"  impulses,  although  another  way  in  which  the 
thalamic  mechanism  could  be  simplified  is  by  atrophy  or  aplasia 
of  certain  cerebellar  connections.  This  question  is  accordingly 
ripe  for  histopathological  study. 

The  writer  does  not  assume  that  hyperkinesis  is  always  or 
often  produced  in  the  way  indicated,  but  regards  the  work  as 
pointing  once  more  to  the  study  of  tissue-simplification  with 
selective  loss  of  neurones  as  contributing  to  the  explanation  of 
symptoms.  Thus,  if  exaggerated  knee-jerks  are  found  corre- 
lated with  simplification  of  spinal  cord  mechanisms,  so  more  com- 
plicated forms  of  hyperkinesis  may  be  found  due  to  simplifica- 
tions of  more  complicated  structures. 

Southard,  E.  E.  Analysis  of  Recoveries  at  the  Psychopathic 
Hospital,  Boston:  I.  One  Hundred  Cases,  1912-13,  con- 
sidered especially  from  the  Standpoint  of  Nursing.  Being 
Contribution  from  the  Psychopathic  Hospital,  Boston, 
Mass.,  No.  48  (1914.14).  Boston  Medical  and  Surgical 
Journal,  Sept.  24,  1914,  CLXXI,  478-483. 

Remarks. 

Future  analyses  may  be  made  more  thorough,  and  the  elements 
of  recovery  may  stand  out  more  clearly  in  detail.  Suffice  it  to 
say  that  a  superficial  analysis  like  the  present  amply  proves 
several   points. 

First.  —  The  component  of  nursing  cannot  be  omitted  from 
these  recoveries,  brief  as  was  the  time  of  the  hospital  stay  of  the 
majority  of  cases.  This  is  proved  by  the  incidence  of  disorder 
of  heat-regulation  (fever,  hypothermia)  in  at  least  37  per  cent 
of  the  cases. 

Second.  —  The  special  value  of  nursing,  and  particularly  of 
hydrotherapy,  stands  out  from  the  results  of  the  treatment  of 
alcoholic  psychoses,  which  though  they  form  only  about  one- 
ninth  of  our  problem  of  first  care,  represent  almost  nine-tenths 
of  our  early  therapeutic  results. 

Third.  —  The  recoveries  in  the  so-called  "recoverable"  forms 
of  insanity  take  too  long  to  be  represented  in  any  numbers  in 


115 

this  first  hundred  of  recoveries,  and  it  may  be  suspected  that  the 
average  hospital  stay  of  three  to  four  weeks  is  not  sufficient  for 
recoveries  in  groups  like  manic-depressive  insanity. 

Fourth.  —  The  effect  of  psychotherapy  as  applied  in  the 
Psychopathic  Hospital  is  not  a  rapid  effect. 

Fifth.  —  The  percentage  of  syphilis  in  the  recovered  cases  is 
exactly  that  of  the  total  intake  of  the  hospital,  so  that  this 
factor  cannot  be  said  to  influence  treatment  unfavorably  (two 
questionable  syphilitic  cases  are  more  fully  discussed  and  reference 
made  to  Kraepelin's  analysis  of  allied  conditions). 

Sixth.  —  Some  index  of  the  activities  of  our  after-care  service 
is  afforded  by  the  fact  that  nearly  half  of  the  patients  either 
resorted  voluntarily  or  (in  some  cases)  were  brought  to  the  out- 
patient department  at  one  or  more  periods  subsequent  to  the 
discharge. 

Seventh.  —  The  need  is  apparent  of  nurses  who  shall  build 
their  psychopathic  training  on  a  sound  basis  of  general  hospital 
work  (letter  quoted,  to  the  committee  of  superintendents,  dealing 
with  the  general  aspects  of  the  nursing  problem  for  the  insane). 

Southard,  E.  E.  On  the  Topographical  Distribution  of  Cortex 
Lesions  and  Anomalies  in  Dementia  Prsecox,  with  Some 
Account  of  their  Functional  Significance.  Being  Contribu- 
tion from  the  Massachusetts  State  Board  of  Insanity  No. 
25  (1914.5),  and  Danvers  State  Hospital  Contribution  No. 
53.  The  substance  of  this  contribution  was  presented  at  a 
meeting  of  the  American  Neurological  Association  held  at 
the  Triennial  Congress  of  Physicians  and  Surgeons,  Wash- 
.  ington,  D.  C,  May,  1913.  American  Journal  of  Insanity, 
.      Baltimore,  1914-15,  LXXI,  383-403. 

Conclusions. 

1.  The  writer  has  followed  up  his  earlier  work  on  the  dementia 
prsecox  group  (1910)  with  a  more  systematic  anatomoclinical 
study  of  25  cases,  having  a  view  to  (a)  definite  conclusions  as 
to  the  structurally  ("organic  nature")  of  the  disease,  and  (b) 
correlation  of  certain  major  symptom  groups  (delusions,  cata- 
tonic symptom  groups,  auditory  hallucinosis)  with  disease  of 
particular  brain  regions. 

2.  As  to  (a),  the  structurality  of  dementia  prcecox,  the  writer 
feels  that  the  disease  must  be  conceded  to  be  in  some  sense 
structural,  since  at  least  90  per  cent  of  all  cases  examined   (50 


116 

cases,  data  of  1910  and  1914)  give  evidence  of  general  or  focal 
brain  atrophy  or  aplasia  when  examined  post  mortem,  even  with- 
out the  use  of  the  microscope. 

3.  Moreover,  with  the  use  of  the  microscope,  the  problem  of 
the  normal-looking  remainder  can  perhaps  be  solved,  since  the 
only  two  normal-looking  brains  in  the  1914  series  of  25  yielded 
abundant  appearances  of  cell-destruction  and  satellitosis  in  the 
cerebral  cortex,  which  had  not  yet  had  time  to  be  registered  in 
the  gross  (cases  of  three  weeks'  and  two  months'  duration,  re- 
spectively). 

4.  The  method  of  anatomical  analysis  in  the  new  series  is  a 
more  systematic  one  than  has  been  hitherto  employed,  involving 
careful  gross  description  of  the  fresh  brain;  careful  preservation 
(by  suspension  from  basal  vessels)  in  formaldehyde  solution; 
systematic  photography  to  scale  of  the  superior,  inferior  (cere- 
bellum removed),  lateral  and  mesial  aspects  before  and  after 
stripping  the  pia  mater;  study  of  all  aspects  of  the  brain  as  spread 
side  by  side  in  photographic  form;  further  study  of  the  preserved 
brains  in  the  light  of  the  photographic  study;  and  eventual  cyto- 
logical  or  fiber  studies  of  paired  structures  showing  possible 
atrophy  or  aplasia. 

5.  The  neuropathologist  making  such  a  brain  analysis  shortly 
discovers  that  there  is  often  more  to  be  learned  from  the  gross 
than  from  the  microscopic  appearances,  since,  of  two  gyri,  the  one 
measurably  smaller  than  the  other  (and  therefore  probably 
agenesic,  aplastic  or  atrophic),  the  microscopic  appearances  may 
often  be  hard  to  diagnosticate,  as  the  normal-looking  gyrus  at  the 
time  of  death  may  be  just  undergoing  a  satellitosis  actually  indi- 
cating more  disease  than  its  shrunken  fellow. 

6.  Nevertheless,  the  gross  analysis  gives  one  perfectly  convinc- 
ing evidence  of  some  kind  of  lesions,  leaving  to  other  methods  of 
study  the  decision  as  to  the  congenital  or  acquired  nature  of  these 
lesions.  Some  14  of  the  25  cases  may  be  regarded  as  in  some 
sense  maldevelopmental,  so  as  to  arouse  the  suspicion  that  the 
acquired  atrophy  was  grafted  on  top  of  a  congenital  agenesia  or 
aplasia;  but,  in  the  opinion  of  the  writer,  aplasia  is  indicated 
rather  than  agenesia.  The  potential  victim  of  dementia  prsecox 
is  probably  born  with  the  normal  stock  of  brain  cells,  although 
their  arrangement  and  development  are  at  times  early  interfered 
with. 

7.  The  atrophies  and  aplasias,  when  focal,  show  a  tendency  to 
occur  in   the  left  cerebral  hemisphere.      The   coarse   atrophy  is 


117 

usually  of  only  moderate  degree,  and  often  does  not  appreciably 
alter  the  brain  weight,  at  least  outside  the  limits  of  expected 
variation.  In  fact,  the  heart,  the  liver,  the  kidneys  and  the 
spleen  tend  to  show  greater  loss  in  weight  than  does  the  brain. 

8.  More  remarkable  than  the  atrophy  and  aplasia  of  the  cortex 
is  the  high  proportion  of  cases  of  internal  hydrocephalus  (at  least 
9  cases)  uncovered  by  the  systematic  photographic  study  of 
frontal  sections. 

9.  There  is  no  evidence  that  this  internal  hydrocephalus  is  due 
to  generalized  brain  atrophy.  It  is  possible  that  it  begins  more 
posteriorly.  It  is  probable  that  it  does  not  mechanically  so  much 
affect  the  frontal  lobes.  It  is  associated  with  cases  of  long  dura- 
tion,  although  not  with  all  cases  of  long  duration,  and  was  never 
found  in  cases  of  brief  duration.  Clinically,  the  hydrocephalic 
cases  are  uncommonly  catatonic,  and  the  cases  of  marked  general- 
ized hydrocephalus  were  as  a  rule  victims  of  hallucinations.  De- 
lusions, except  fantastic  delusions,  were  not  prominent  in  this 
group.  The  clinical  courses  of  these  hydrocephalic  cases  were 
more  than  usually  active  and  mutual,  and  were  often  interrupted 
by  remissions. 

10.  The  hydrocephalic  brains  were  not  in  other  respects  par- 
ticularly open  to  the  suspicion  of  congenital  disease;  and,  without 
adequate  proofs,  the  writer  is  inclined  to  consider  the  hydro- 
cephalus to  be  often  an  acquired  hydrocephalus. 

11.  An  ardent  supporter  of  congenital  features  might  claim 
that  19  of  the  25  brains  showed  some  sort  of  maldevelopmental 
defect.  One  impartial  witness  thought  that  14  showed  such. 
And  even  if  all  9  cases  of  hydrocephalus  be  taken  as  acquired,  we 
remain  with  11  cases  bearing  pretty  certain  evidence  of  malde- 
velopmental defect.  On  the  other  hand,  all  but  6  cases  showed 
signs  of  acquired  lesion,  and  these  6  showed  various  microscopic 
changes  of  doubtful  meaning,  but  certainly  acquired. 

12.  One  remains  with  the  general  impression  that  gross  altera- 
tions are  almost  constant,  and  microscopic  changes  absolutely 
constant,  and  that  the  high  proportion  of  gross  appearances  sug- 
gesting aplasia  means  that  structural  (visible  or  invisible)  changes 
of  a  maldevelopmental  nature  lie  at  the  bottom  of  the  disease 
process.  But  this  suspicion  of  underlying  maldevelopment  is 
only  a  suspicion,  although  a  strong  one,  and  the  first  factor  for 
the  theory  of  pathogenesis  to  explain  is  the  gross  and  microscopic 
changes  as  they  present  themselves  in  the  full-fledged  case. 

13.  Aside   from   left-sidedness    of   lesions   and   internal   hydro- 


118 

cephalus,  very  striking  is  the  preference  of  these  changes  to 
occupy  the  association-centers  of  Flechsig.  For  this  there  is 
probably  good  a  priori  reason  in  the  structure,  late  evolutionary 
development,  and  consequent  relatively  high  lability  of  these 
regions.  The  interest  of  these  findings  is  still  greater  in  the  func- 
tional connection  (see  below). 

14.  In  concluding  this  summary  of  the  anatomical  side  of  the 
study,  the  writer  cannot  forbear  adding  that  he  supposes  many 
neurologists,  hearing  of  "lesions/'  will  at  once  imagine  extirpa- 
tory  lesions  of  a  Swiss-cheese  appearance  or  areas  like  those  of 
tuberous  sclerosis.  At  the  risk  of  being  charged  with  naivete,  the 
writer  would  again  here  insist  that  the  lesions  described,  though 
never  beyond  the  range  of  a  skilful  anatomist,  are  of  a  mild 
atrophic  nature  or  in  the  nature  of  aplasias,  requiring  care  and 
deliberation  in  their  description  and  explanation,  and  often  hard 
to  grasp  except  where  photographs  of  all  sides  of  the  brain  may 
be  compared  at  once  and  reference  then  made  to  the  brains  them- 
selves. These  lesions  do  not  effect  globar  lacunse  in  the  cortical 
neuronic  systems,  but  they  are  of  a  more  finely  selective  char- 
acter. Under  the  microscope  it  may  be  difficult  to  say,  without 
elaborate  micrometry,  that  one  area  is  worse  off  than  another; 
but  convincing  evidence  of  the  gross  convolutional  extent  of  the 
process  is  got  by  the  naked  eye  and  by  the  finger. 

15.  The  writer  regards  this  work  as  putting  the  burden  of  proof 
on  those  who  claim  the  essential  functionality  of  dementia  prsecox, 
and  is  at  some  pains  to  couch  objections  to  one  formulation  of 
these  changes  as  "incidental,"  and  to  another  as  "agenesic." 
Nevertheless,  the  writer  would  not  necessarily  deny  the  value  of 
those  formulations  which  look  on  these  cases  as  cases  of  faulty 
adaptation  to  environment. 

16.  As  to  (b),  the  functional  correlations  of  this  study,  the  re- 
sults may  be  summed  up  by  saying  that  strong  correlations  have 
been  found  to  support  the  writer's  former  claims  that  (1)  delu- 
sions are  as  a  rule  based  on  frontal  disease,  and  (2)  catatonic 
symptoms  on  parietal-lobe  disease.  An  equally  strong  correlation 
(3)  has  now  been  found  between  auditory  hallucinosis  and  tem- 
poral-lobe disease. 

17.  The  writer's  previous  work  had  suggested  a  correlation 
between  frontal-lobe  disease  and  delusion-formation.  This  cor- 
relation is  not  so  decided  in  the  present  series,  since,  although 
perhaps  only  1  of  the  25  cases  failed  to  exhibit  delusions,  7  of 
the  remaining  24  failed  to  show  frontal-lobe  lesions.     However, 


119 

2  of  these  7,  though  grossly  negative,  were  microscopically  posi- 
tive enough. 

18.  The  findings  indicate,  accordingly,  that  there  is  a  group  of 
delusional  cases  such  that  even  long  duration  does  not  determine 
a  frontal  emphasis  of  lesions.  Five  cases  represent  this  excep- 
tional condition;  3  of  these  5  are  probably  best  interpreted  as 
cases  of  hyperphantasia  in  which,  both  a  priori  and  by  observa- 
tion, frontal  lesions  are  not  characteristic. 

19.  On  the  whole,  the  correlation  between  delusions  and  focal 
brain  atrophy  (or  aplasia  capped  by  atrophy?)  is  very  strong, 
particularly  if  we  distinguish  (1)  the  more  frequent  form  of  delu- 
sions with  frontal-lobe  correlations  from  (2)  a  less  frequent  form 
with  parietal-lobe  correlations. 

20.  The  non-frontal  group  of  delusion-formations  the  writer 
wishes  to  group  provisionally  under  the  term  hyperphantasia, 
emphasizing  the  overimagination  or  perverted  imagination  of 
these  cases,  the  frequent  lack  of  any  appropriate  conduct-disorder 
in  the  patients  harboring  such  delusions,  and  the  a  priori  likeli- 
hood that  these  cases  should  turn  out  to  have  posterior-associa- 
tion-center disease  rather  than  disease  of  the  anterior  association- 
center.     This  anatomical  correlation  is,  in  fact,  the  one  observed. 

21.  The  writer's  previous  work  had  suggested  a  possible  corre- 
lation between  catatonic  phenomena  and  parietal  (including  post- 
central) disease.  Ten  of  14  definitely  catatonic  cases  yielded 
parietal  or  other  post-Rolandic  lesions;  2  were  grossly  negative, 
but  microscopically  altered;  and  indications  of  correlation  ap- 
peared also  in  the  remaining  2.  Five  of  7  clinically  somewhat 
doubtfully  catatonic  cases  yielded  similar  correlations.  Four 
clinically  non-catatonic  cases  yielded  no  parietal  correlations.  (It 
is  worth  while  insisting  that  "catatonia"  is  here  used  to  refer  to 
a  symptom,  not  to  an  entity  or  clinical  group.) 

22.  Special  interest  attaches  to  cerea  flexibilitas  as  a  clearly 
definable  form  of  catatonic  symptom.  Four  of  5  cases  yielded 
gross  parietal  lesions.  The  fifth  case  was  one  of  the  entirely  nega- 
tive cases  in  the  gross,  but  showed  very  marked  postcentral 
satellitosis  microscopically.  Two  of  these  cases  showed  the  gross 
emphasis  of  lesions  in  the  postcentral  gyri,  thereby  hinting  at  an 
explanation  of  cerea  flexibilitas  along  the  lines  of  a  reaction  to 
altered  kinesthesia  or  an  altered  reaction  to  normal  kinesthesia 
(depending  upon  such  true  analysis  of  intragyral  cortex-function 
as  the  future  may  bestow). 

23:  A  priori  one  might  expect  a  correlation  between  the  char- 


120 

acteristic  auditory  hallucinosis  found  in  many  cases  of  dementia 
prsecox  and  temporal-lobe  lesions.  In  point  of  fact,  9  of  12 
hallucinated  cases  yielded  temporal-lobe  atrophy  or  aplasia;  and 
actually  only  1  of  the  3  others  is  a  good  exception  to  the  rule 
(from  the  clinical  standpoint),  to  say  nothing  of  the  fact  that 
this  case  had  ample  microscopic  changes  in  the  temporal  lobe. 

24.  Of  the  13  wow-hallucinating  (auditory)  cases,  only  3,  or  at 
most  4,  could  be  said  to  have  temporal-lobe  lesions  suggesting 
the  possibility  of  hallucinosis.  Here  we  may  appeal  to  the  in- 
adequacy of  clinical  work,  or,  better,  to  the  non-suitability  of 
the  lesions,  since  no  one  would  assert  that  we  yet  have  any  idea 
of  the  precise  and  intimate  temporal-lobe  conditions  which  permit 
hallucinations. 

25.  In  these  functional  connections  the  more  recent  formula- 
tions of  Kraepelin  and  of  Bleuler  have  been  reviewed,  although 
the  entire  work  was  done  without  the  benefit  of  their  analyses. 
The  present  formulation  appears  consistent  enough  with  either. 
It  would  seem  that  Kraepelin  regards  a  correlation  between  audi- 
tory hallucinosis  and  temporal-lobe  disease  as  already  highly 
probable  from  the  literature.  He  also  goes  so  far  as  to  incrimi- 
nate the  "central"  region  for  motor  disorders.  But  the  present 
suggestions  as  to  the  possible  kinesthetic  relations  of  catatonia 
and  the  special  (frontal  and  parietal)  correlations  with  delusion- 
formation  are  not  suggested  by  Kraepelin  from  the  literature 
available. 

26.  It  is  interesting  to  note  that  further  study  by  the  Munich 
workers  seems  to  have  drawn  attention  away  from  the  infrastellate 
cortical  changes  sketched  by  Alzheimer  for  catatonia  in  1897  to 
various  suprastellate  changes.  The  microscopic  work  done  in  the 
present  study  in  connection  with  certain  grossly  negative  cases 
indicates  that  the  early  phases  of  the  process  may  very  often  look 
as  if  infrastellate  change  was  to  be  the  most  striking  product  of 
the  disease.  This  is  perhaps  due  to  a  richer  original  supply  of 
glia  cells  in  these  infrastellate  layers.  Later,  when  the  process 
is  less  acute,  it  may  often  be  found  that  suprastellate  cell  losses 
are  much  more  in  evidence  than  any  striking  infrastellate  change. 

27.  As  for  the  general  position  which  this  work  would  assume 
toward  the  functional  conclusions  of  Bleuler,  it  would  seem  that  a 
histopathological  basis  for  "dissociations"  or  "schizophrenia" 
could  be  somewhat  readily  provided  by  the  lesions  found,  since 
these  are  for  long  periods  mild  enough  and  sufficiently  confined 
to  the  finer  cortical  apparatus  to  provide  for  the  exquisite  mental 


121 

changes  of  most  cases.  The  main  neuronic  S}'stems  are  often 
permanently  preserved,  leaving  an  irregularly  and  slightly  simpli- 
fied corticd  apparatus,  in  which  a  few  cell  changes  would  nat- 
urally throw  out  of  co-ordination  a  great  deal  of  still  intact 
apparatus.  But  the  whole  process  often  remains  so  mild  as  to 
permit  re-establishment  of  relatively  normal  functional  relations 
on  a  slightly  simplified  basis,  the  whole  to  be  disturbed  once 
more  on  the  occasion  of  the  death  or  disease  of  a  few  more  cells. 
Very  striking  is  the  fact  that  the  cells  not  attacked  are,  so  far  as 
we  can  see,  normal  enough. 

28.  This  work  is  rather  a  study  of  genesis  than  of  etiology,  in 
the  sense  of  modern  medical  distinctions  between  these  branches 
of  inquiry.  It  is  a  modest  inquiry  into  factors,  and  does  not  rise 
to  the  height  of  ascribing  causes.  The  writer  will  refer  merely 
to  some  paragraphs  in  the  text  as  to  a  possible  ontological  posi- 
tion concerning  structure  and  function  which  the  future  may  take. 
The  deplorable  thing  is  that  some  structuralists  throw  out  of 
court  all  functional  data  and  some  (rather  more!)  functionalists 
tend  to  underrate  the  possible  contributions  of  anatomy  to  this 
field.  Luckily,  science  nowadays  cannot  long  proceed  merely 
a  la  mode. 

29.  In  particular,  to  sum  up,  I  would  call  especial  attention  to 
the  following  points:  (1)  the  constancy  of  mild  general  or  focal 
atrophies  in  cases  lasting  long  enough  to  yield  these;  (2)  the 
tendency  to  an  exhibition  of  lesions  somewhat  more  markedly  in 
the  left  hemisphere;  (3)  the  preference  of  the  lesions  for  the 
"association-centers"  of  Flechsig;  (4)  the  high  correlation  of 
auditory  hallucinosis  and  temporal-lobe  lesions,  as  also  (5)  of 
catatonia  and  parietal  lesions  (cerea  flexibilities,  especially  post- 
central), and  (6)  of  the  more  frequent  form  of  delusions  and 
frontal-lobe  disease;  (7)  the  possible  existence  of  a  hyperphan- 
tasia  group  with  parietal  correlations,  and  of  (8)  a  large  internal 
hydrocephalus  group  with  catatonic  and  hallucinotic  correlations 
rather  than  delusional.  A  few  more  points  can  be  got  from  the 
description  of  the  plates. 


122 

Southard,  E.  E.  Notes  on  Public  Institutional  Work  in  Mental 
Prophylaxis,  with  Particular  Reference  to  the  Voluntary 
and  "Temporary  Care"  Admissions  and  the  "Not  Insane" 
Discharges  at  the  Psychopathic  Hospital,  Boston,  1912-13. 
Being  Contribution  from  the  State  Board  of  Insanity,  No. 
22  (1914.2).  Journal  of  American  Medical  Association, 
Chicago,  Nov.  28,  1914,  LXIII,  1898-1903. 

Summary. 

1.  In  the  prophylactic  division  of  mental  hygiene  the  matter 
of  voluntary  admissions  to  hospitals  for  the  insane  holds  a  pri- 
mary place.  Their  number  is  increased  by  the  plan  of  supporting 
such  at  the  public  charge  just  as  committed  cases  are  supported, 
and  is  still  further  increased,  and  even  doubled,  by  the  provision 
of  a  modern  psychopathic  hospital  (increase  from  8  to  16  per 
cent  of  the  total  of  voluntary  and  committed  cases,  experience 
at  Boston  Psychopathic  Hospital). 

2.  A  second  prophylactic  measure  is  the  provision  of  proper 
temporary  care  for  persons  suspected  of  mental  disease,  as  ac- 
cording to  a  unique  Massachusetts  temporary  care  law  (first 
operative  in  1911;  see  text).  This  provision  has  been  eagerly 
employed  in  Massachusetts,  more  than  doubling  the  number  each 
year  since  enactment.  The  Psychopathic  Hospital  is  receiving 
about  two-thirds  of  all  those  thus  received  in  Massachusetts, 
1913. 

3.  Many  important  prophylactic  questions  relate  to  those 
thought  to  be  insane  but  not  proved  to  be.  In  this  psychiatric 
borderland  also  lie  many  questions  between  insanity  and  feeble- 
mindedness. A  large  "not  insane"  group,  namely,  570  cases 
among  the  first  2,500  discharges  from  the  Psychopathic  Hospital, 
has  been  reviewed  to  discern  the  general  features  of  this  psychi- 
atric borderland  of  diagnosis. 

4.  Consideration  is  omitted  of  372  additional  cases  regarded  as 
recovered  or  improved  after  attacks  of  mental  disease,  although 
in  one  sense  these  cases  are  open  to  prophylactic  measures,  since 
the  occasional  review  of  these  cases  by  a  follow-up  system  must 
tend  to  help  society,  and  may  help  the  individual. 

5.  Of  the  570  not  insane  cases,  179  were  cases  of  feeble- 
mindedness of  various  grades,  largely  of  the  higher  grades  and 
including  a  large  number  of  the  so-called  defective  delinquents 
.(more  than  fifty).  In  this  connection  it  often  becomes  necessary 
to  fight  a  bureaucratic  tendency  among  social  workers,  who  tend 


123 

to  proceed  on  the  erroneous  assumption  that  an  insane  or  a 
feeble-minded  person  belongs  by  definition  in  some  public  or 
semipublic  institution. 

6.  The  numerically  next  largest  group  is  that  of  psychoneu- 
rotics (100),  who  are  largely  female  (71),  especially  the  hysterics 
(39  female  in  45).  Consideration  is  given  to  the  idea  of  a  public 
sanatorium  or  preventorium  for  such  persons  with  far  larger 
provisions  for  females  than  for  males.  It  is  thought  that  these 
cases,  forming  at  least  a  twenty-fifth  (probably  more)  of  all 
mental  cases  in  the  community,  and  at  least  a  fourth  (perhaps 
somewhat  more)  of  all  not  insane  mental  cases,  might  perhaps 
warrant,  if  combined  with  the  convalescents,  the  establishment 
of  a  public  sanatorium  to  be  run  on  economical  lines  in  the 
country. 

7.  It  is  largely  the  great  expense  (from  $20  to  $25  per  week)  of 
caring  for  these  cases  in  a  centrally  placed  psychopathic  hospital 
or  psychiatric  clinic  which  determines  the  idea  of  a  rural  public 
sanatorium;  for  psychotherapy  (in  whatever  form  may  be  de- 
termined to  be  valuable),  rest  treatment,  work  treatment  and 
calisthenics,  to  say  nothing  of  dietary  and  other  general  measures, 
can  be  as  well,  though  more  expensively,  carried  out  in  the  urban 
psychopathic  hospital. 

8.  Of  the  570  not  insane  discharges,  165  were  not  classified  as 
showing  any  particular  form  of  mental  or  other  defect,  although 
it  must  be  emphasized  that  each  of  these  came  for  psychodiag- 
nostic  reasons,  and  was  admitted  under  a  special  form  of  law. 
One  even  was  a  case  regularly  committed  under  judicial  proce- 
dure, but  later  determined  to  be  not  insane,  and  nine  others  came 
under  judicial  authority  by  virtue  of  certain  other  laws  not  com- 
monly used. 

9.  Of  these  165  not  insane  discharges,  90  had  been  admitted 
under  the  temporary-care  law,  unique  in  Massachusetts,  referred 
to  in  paragraph  2  (except  in  fifteen  instances  in  which  a  some- 
what similar  law,  operating  for  the  city  of  Boston  alone,  was 
employed).  With  respect,  to  these  persons  it  must  be  emphasized 
that  their  problems  would  not  have  been  so  easily  solved  under 
any  other  procedure.  Examples  of  such  problems  are  question 
of  paraphrenia  systematica,  question  of  hysteria,  question  of 
defective  delinquent,  question  of  epilepsy,  etc. 

10.  Of  the  165  not  insane  discharges,  65  either  resorted  volun- 
tarily to   the  hospital  or  were  pursuaded  to   become  voluntary 


124 

patients.  It  is  evident  that,  in  an  increasing  number  of  instances, 
persons  realize  or  can  be  made  to  realize  the  possible  psycho- 
pathic nature  of  their  difficulties  and  come  almost  eagerly  even 
to  a  public  institution. 

11.  About  13  per  cent  (18  in  136)  of  these  persons  who  were 
discharged  as  without  active  symptoms  of  mental  or  other 
disease  yielded  positive  Wassermann  reactions  in  their  serums. 
The  interpretation  of  this  fact  is  doubtful.  The  percentage  in 
the  males  was  10  (7  in  65),  in  females  16  (11  in  71). 

12.  Two-thirds  of  the  patients  aged  six  to  fifteen  were  boys 
(21  boys,  10  girls),  but  of  those  aged  sixteen  to  twenty-five, 
there  were  more  than  four  times  as  many  women  as  men  (10 
men,  45  women).  From  twenty-six  to  forty,  the  sexes  are  about 
evenly  distributed  (17  men,  19  women).  Then  males  preponde- 
rate (28  men,  14  women).  Thus,  women  may  be  thought  to  get 
into  suspicious  psychopathic  circumstances  which  later  resolve, 
much  more  often  in  the  period  of  adolescence;  males  somewhat 
more  often  in  late  boyhood  and  in  postadolescent  years.  Therein 
lodges  a  problem  in  prognosis  which  if  settled  would  greatly  aid 
the  alienist,  particularly,  in  making  certain  social  decisions. 

13.  It  is  clear  that  the  influences  which  are  bringing  the  not 
insane  to  the  Psychopathic  Hospital  in  Boston  are  bringing  them 
there  at  comparatively  early  ages,  and  often  (especially  the 
females)  in  adolescence.  The  community's  interest  in  the  ques- 
tion of  feeble-mindedness  and  the  social  worker's  often  justifiable 
desire  to  institutionalize  her  wards  are  powerful  factors  in  this 
resort  for  diagnosis  to  a  State  institution.  The  physicians  in  the 
community  are  almost  to  a  man,  I  believe,  pleased  with  the 
increasing  facility  with  which,  under  the  laws  mentioned  above, 
some  of  their  most  difficult  problems  are  solved.  Time  was 
when  almost  the  only  recourse  in  determining  absolutely  whether 
a  patient  was  insane  was  to  adjudge  him  insane  and  release  him 
afterward  if  a  mistake  had  been  made.  To  overcome  this  diffi- 
culty, various  devices  have  been  adopted  in  the  more  highly 
civilized  of  our  States.  The  Massachusetts  arrangements  are  of 
particular  interest  to  those  who  may  not  have  been  able  as  yet  to 
civilize  their  own  States  in  these  directions. 


125 

Southard,  E.  E.  Progress  of  the  Psychopathic  Hospital  on  the 
Prophylactic  Side  of  Mental  Hygiene.  Being  Contribution 
from  the  Psychopathic  Hospital,  Boston,  Mass.,  No.  52 
(1914.18).  Boston  Medical  and  Surgical  Journal,  Dec.  3, 
1914,  CLXXI,  847-850. 

Summary. 
I  will  sum  up  briefly  by  saying  that  the  prophylactic  division 
of  mental  hygiene  can  safely  claim  to  be  far  more  than  a  letter- 
head or  a  propaganda,  and  that,  whatever  its  legal  and  public 
institutional  sides,  the  prophylactic  division  of  mental  hygiene 
has  as  concrete  measures:  — 

1.  The  stimulation  of  proper  temporary  care  of  persons  suffer- 
ing from  mental  derangement  under  the  conditions  of  general 
hospital  and  private  practice. 

2.  The  stimulation  of  voluntary  admissions  to  existing  and 
future  hospitals  for  the  insane. 

3.  The  establishment  of  psychopathic  hospitals  in  proper 
centers,  having  proper  medical  and  social  arrangements  for  the 
highest  forms  of  intramural  and  extramural  individual  and  com- 
munity service.  If  you  are  tempted  to  state  that  the  term 
"psychopathic"  somewhat  resembles  that  blessed  name  "Meso- 
potamia" in  its  drawing  powers,  as  Mr.  Frank  B.  Sanborn  once 
insisted,  yet  I  venture  to  hope  that  its  extension  to  include  both 
the  legally  insane  and  the  great  variety  of  other  mental  cases, 
including  psychoneurotics,  mentally  deficients,  and  criminalistic 
and  possibly  other  types  of  mental  disorder,  will  tend  to  abolish 
the  use  of  the  term  "insane"  by  physicians,  except  under  court 
conditions.  The  term  "insane"  is  rightfully  considered  a  legal 
and  not  a  medical  term.  One  of  the  greatest  features  of  a  mental 
hygiene  propaganda  will  be  to  convince  and  to  persuade  the 
world  of  this  fact. 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  Normal- 
looking  Brains  in  Psychopathic  Subjects:  Second  Note 
(Westborough  State  Hospital  Material).  Journal  of  Nervous 
and  Mental  Disease,  New  York,  1914,  XLI,  775-782. 

Conclusions. 
1.  The  writers  have  tested  former  issues  concerning  the  func- 
tionality    of    mental    disease    (derived    from    a    comparison    of 
Worcester  autopsy  material  and  that  from  Dan  vers)  by  a  study  of 


126 

Westborough  material  in  which  neither  a  bias  towards  function- 
ality nor  a  bias  toward  structurality  ("organic  nature")  was 
likely. 

2.  The  Worcester  proportion  of  normal-looking  brains  in  a 
series  of  psychopathic  subjects  was  about  1  in  3,  the  Danvers 
proportion,  about  1  in  4;  the  Westborough  proportion  proves  to 
be  about  1  in  7. 

3.  The  Westborough  standards  tend  to  overthrow  the  idea  of 
the  essential  functionality  of  various  senile  cases,  an  idea  that 
was  suggested  both  by  the  Danvers  and  the  Worcester  series  of 
autopsies. 

4.  As  to  the  moot  question  of  dementia  prsecox,  the  West- 
borough results  stand  nearer  the  Danvers  results,  exhibiting  a 
scant  majority  of  gross-lesion  cases  as  against  the  long,  entirely 
negative  series  at  Worcester,  and  the  high  percentages  of  gross 
lesion  found  at  Danvers. 

5.  In  a  previous  study  use  was  made  of  a  principle  that  ex- 
tensive microscopic  changes  may  be  wholly  consistent  with  a 
grossly  normal  brain  appearance  up  to  a  period  not  yet  accu- 
rately established  (say  three  months).  In  point  of  fact,  11  per 
cent  of  the  Worcester  series  (26  cases)  and  16  per  cent  of  the 
Westborough  series  (12  cases)  had  a  total  duration  of  symp- 
toms of  three  months  or  less. 

6.  Practically,  it  is  often  a  year  or  more  before  visible  and 
tangible  changes  in  the  brain  of  an  undoubted  character  set  in, 
and  15  per  cent  of  the  Worcester  series  (36  cases)  and  33  per 
cent  of  the  Westborough  series  (24  cases)  had  durations  of  a 
year  or  less. 

7.  Perhaps  it  is  too  much  to  ask  the  anatomist  at  the  autopsy 
table  to  diagnosticate  the  results  of  the  finer  diffuse  destructive 
changes  (non-globar,  not  affecting  the  projection  system)  which 
have  lasted  but  a  year  or  less. 

8.  Practically  we  look  for  recoveries  up  to  three  years,  more 
or  less;  53  per  cent  of  the  Worcester  series  (132  cases)  and  58 
per  cent  of  the  Westborough  series  (42)  had  lasted  but  three 
years  or  less.  Such  cases  may  well  show  (and  many  of  them 
have  shown,  though  it  is  not  our  design  to  describe  them)  micro- 
scopic changes  of  an  important  reversible  or  non-destructive 
character. 

9.  Research  should  accordingly  be  bent  upon  those  long-stand- 
ing cases  which  nevertheless  show  no  gross  effects  of  their  dis- 
ease in  the  brain.     The  microscope  may  discover  in  this  group 


127 

either  (a)  evidences  of  reversible  brain-cell  changes  such  that 
they  never  produce  any  gross  effects  (physical  or  chemical 
changes  not  interfering  with  cell  nuclei  or  other  vegetative 
mechanisms),  or  (b)  no  evidences  of  morbid  brain  changes  what- 
ever, but  merely  such  appearances  as  are  consistent  with  the 
brain's  reacting  normally  to  influences  ab  extra. 

10.  These  orientation  studies  show  how  seldom  are  all  the  con- 
ditions right  for  testing  such  an  hypothesis  as  that  of  the  intrinsic 
normality  of  brain  mechanisms  whose  reactions  are  taking  effect 
in  extrinsic  abnormality,  i.e.,  the  hypothesis  that  mental  disease 
may  be  entirely  functional  so  far  as  the  brain  is  concerned. 

11.  Accordingly,  we  seem  still  father  away  from  a  strict  proof 
that  "the  whole  cortex,  or  even  the  whole  nervous  system,  might 
be  intrinsically  normal  but  extrinsically  abnormal  in  its  reactions 
to  a  given  chemical,  physical  or  other  condition." 

Southard,  E.  E.,  and  Bond,  E.  D.  Clinical  and  Anatomical 
Analysis  of  11  Cases  of  Mental  Disease  arising  in  the 
Second  Decade,  with  Special  Reference  to  a  Certain  Type 
of  Cortical  Hyperpigmentation  in  Manic-depressive  In- 
sanity. (Danvers  State  Hospital  Series  No.  38.)  (Proceed- 
ings, American  Medico-Psychological  Association,  1914, 
223-235. 

Conclusions. 

1.  This  work  is  another  instalment  of  work  designed  to  throw 
light  on  the  age  factor  in  the  production  of  mental  disease,  and 
has  the  same  features  of  random  selection,  employing  only 
autopsied  cases,  from  a  long  series,  as  did  previous  work  from  the 
Danvers  State  Hospital  laboratory  on  cases  having  onset  in  the 
sixth  and  seventh  decades  (1908)  and  in  the  fifth  decade  (1913). 

2.  There  turned  out  to  be  surprisingly  few  cases  for  the  an- 
alysis; somewhat  less  than  2  per  cent  of  a  long  series  of  autopsied 
cases  (18  in  938)  proved  to  be  cases  having  onset  of  mental 
disease  between  ten  and  twenty  years. 

3.  The  age  distribution  in  the  11  cases  which  proved  suitable 
for  full  clinical  and  anatomical  correlations  is  striking;  of  these 
11,  8  had  onset  between  seventeen  and  twenty  years,  and  5  of 
these  8  at  seventeen  years;  the  age  distribution,  so  far  as  it 
goes,  suggests  disorder  at  puberty  as  somehow  related  with  the 
onset  of  the  first  attack. 

4.  Omitting  one  female  epileptic  which  demented,  we  find  the 
cases  equally  distributed  between  manic-depressive  insanity  and 


128 

dementia  praecox.  The  manic-depressive  5  were  composed  of  4 
females  (1  of  rather  doubtful  diagnosis)  and  1  male.  The  de- 
mentia praecox  5  were  composed  of  3  females  and  2  males.  Four 
of  the  5  dementia  praecox  cases  were  subject  to  tuberculosis;  1 
of  the  manic-depressives  was  tuberculous. 

5.  The  lipoid  disorder,  of  which  we  attempted  to  get  an  index 
by  a  study  of  the  distribution  of  certain  substances  stainable  by 
the  Heidenhain  iron-hematoxylin  method,  was  far  more  in  evi- 
dence in  the  manic-depressive  series  than  in  the  dementia  praecox 
series. 

6.  The  three  cases  with  most  marked  pigmentation  (in  this 
specialized  sense)  were:  (a)  the  epileptic  dement  above  men- 
tioned, onset  at  thirteen,  attacks  till  death  at  fifty-nine;  (b)  a 
manic-depressive,  depressed  at  seventeen,  thirty-one  and  thirty- 
two,  maniacal  at  forty-nine,  dead  of  intercurrent  disease  at  forty- 
nine;  and  (c)  a  manic-depressive,  very  numerous  attacks  of  de- 
pression, first  at  eighteen  to  twenty,  7  known  attacks  between 
fifty-eight  and  death  at  sixty-eight.  The  other  three  manic- 
depressive  cases  showed  marked  (although  less  marked)  pigmen- 
tation focally  in  {<£),  the  doubtful  case  above  mentioned  (in 
which,  indeed,  the  pigment  is  rather  an  index  of  local  metabolic 
disorder  in  an  inflamed  convolution),  and  (e,  /),  cases  dying  at 
twenty-five  and  thirty-one,  respectively. 

7.  The  dementia  praecox  cases  either  showed  no  pigment,  as  in 
(g),  death  at  seventeen  after  nine  months  of  symptoms;  (h), 
death  at  forty-five,  after  thirty  years  of  symptoms;  (i),  death  at 
thirty-two,  twenty  years  after  onset,  or  a  slight  amount,  as  in 
(j),  death  at  twenty-nine  after  nine  years  of  symptoms,  and  (k), 
death  at  twenty-two  after  five  years  of  symptoms  (pigment  in 
occasional  pyramids). 

8.  If  these  findings  should  be  taken  at  their  face  value,  it  might 
be  inferred  that  manic-depressive  insanity  is  more  likely  to  prove 
a  disease  involving  brain-cell  metabolism  than  is  dementia 
praecox.  In  dementia  praecox  there  is  more  evidence  that  certain 
cells  have  been  destroyed  outright;  but  cells  which  escape  de- 
struction are  not  likely  to  look  in  any  respect  abnormal.  In 
manic-depressive  insanity  there  is  not  such  good  evidence  of  cell 
destruction;  on  the  other  hand,  these  cases  seem  to  show  that 
overloading  with  a  certain  kind  of  pigment  is  more  characteristic 
of  the  brain  cells  of  manic-depressives  than  of  precocious  dements. 

9.  The  manic-depressive  cases  of  this  series  seem  to  have  shown 
more  depression  than  mania.     What  the  relation  of  this  may  be 


129 

to  the  histology  of  these  cases  is  doubtful,  but  it  would  seem 
desirable  to  examine  cases  of  long-continued  mania  and  long- 
continued  depression  with  the  same  technique. 

10.  Previous  work  from  this  laboratory  on  age  correlations  with 
pigment  deposits  has  suggested  that  especially  the  neuroglia  cells 
are  likely  to  show  progressively  more  and  more  pigment  with 
advancing  age;  the  present  work,  regardless  of  the  special  entity 
correlations  just  discussed,  seems  to  show  that  youthful  cases  do 
not  show  much  neuroglia-cell  pigment,  and  therefore  this  work 
is  to  that  extent  consistent  with  former  results. 

11.  As  to  the  possible  causes  of  the  pigment  deposits  in  various 
types  of  cell,  perhaps  nothing  better  than  the  mystic  term  "  meta- 
bolic" can  be  risked.  Still,  there  are  two  cases  in  which  there 
were  decidedly  local  accumulations  of  somewhat  similar-looking 
substances  due  to  or  closely  associated  with  acute  inflammatory 
processes  (see  Cases  1  and  10,  dying  at  seventeen  and  twenty- 
two  years,  respectively).  In  these  cases,  to  a  large  extent  en- 
tirely free  from  pigmentation,  either  the  pressure  or  the  toxines 
of  the  inflammation  had  produced  the  same  appearances  focally 
that  are  shown  by  other  non-inflammatory  cases  diffusely.  The 
deposits  are,  then,  possibly  favored  by  certain  factors  working 
ab  extra  with  respect  to  the  cells  in  question. 

Southard,  E.  E.,  and  Stearns,  A.  W.  The  Margin  of  Error  in 
Psychopathic  Hospital  Diagnosis.  Being  Contribution  from 
the  Psychopathic  Hospital,  Boston,  Mass.,  No.  61  (1914.27). 
Boston  Medical  and  Surgical  Journal,  1914,  CLXXI,  895- 
900;   1013. 

Summary. 
The  writers  discuss  the  difference  between  insanity  and  mental 
disease.  Studies  of  similar  scope  at  Danvers  (general  paresis, 
senile  dementia,  psychoses  in  general)  and  at  Worcester  (general 
paresis)  are  mentioned,  and  a  table  is  offered  showing  the  high 
accuracy  which  the  diagnosis  of  general  paresis  had  obtained  even 
before  the  Wassermann  reaction  was  available.  They  remark 
upon  the  frequency  of  "unclassified'-'  cases  at  Danvers  Hospital, 
and  show  a  similar  frequency  at  the  Psychopathic  Hospital, 
Boston. 

It  is  shown  that  about  1  in  5  cases  gets  no  diagnosis  at  the 
Psychopathic,  and  that  of  those  cases  that  do  achieve  a  diagnosis 
1  in  4  has  its  diagnosis  altered  upon  removal  to  a  State  hospital. 
Not  all  of  those  removed  receive  a  definite  diagnosis.     There  is, 


130 

in  fact,  a  residuum   of  about   6  per  cent  that  have  as  yet  re- 
mained unclassified. 

Some  analysis  is  made  of  the  figures  for  five  hospitals  receiving 
the  majority  of  the  Psychopathic  Hospital  patients.  Possible 
bias  in  diagnosis  is  considered,  but  largely  discarded.  The  most 
difficult  field  of  diagnosis  is  shown  to  be  that  of  dementia  prsecox 
and  manic-depressive  psychosis.  It  is  thought  that  the  excited 
or  agitated  patients  of  these  groups  form  the  largest  and  best 
subject  of  diagnostic  and  theoretical  investigation.  Examples  of 
interesting  alterations  of  diagnosis  are  offered,  including  a  case  in 
which  the  terminal  phase  of  an  alcoholic  hallucinosis,  together 
with  incoherence  (perhaps  due  to  attention-disorder)  and 
maniacal  symptoms,  was  the  basis  of  a  diagnosis  of  dementia 
prsecox,  whereas  the  true  diagnosis  was  very  probably  manic- 
depressive  psychosis  combined  with  alcoholic  psychosis. 

Southard,  E.  E.  Applications  of  the  Pragmatic  Method  to 
Psychiatry.  Journal  of  Laboratory  and  Clinical  Medicine, 
St.  Louis,  1919,  V,  139-145. 

Summary. 

1.  Psychiatry  should  more  and  more  adopt  the  "Laboratory 
habit  of  mind,"  become  more  and  more  pragmatic,  and  bring 
itself  in  line  with  the  rest  of  medicine. 

2.  Seven  applications  of  the  pragmatic  method  to  psychiatry 
are  offered :  — 

(a)  It  makes  a  difference  to  the  patient  whether  he  is  seen  by 
a  psychiatrist  or  by  a  clinical  neurologist.  There  is  thus  for  the 
moment  a  real  difference  between  psychiatry  and  clinical  neu- 
rology, though  the  future  may  destroy  that  difference  and  produce 
"  neuropsychiatry. " 

(6)  It  makes  a  difference  to  the  patient  whether  we  take 
"insanity"  as  a  unit  or  as  a  collection  of  entities.  The  prag- 
matic rule  decides  in  favor  of  a  pluralistic  view  of  mental  diseases. 

(c)  The  principle  of  orderly  exclusion  in  the  diagnosis  of  com- 
plicated cases  is  of  pragmatic  value. 

(d)  Especially  is  this  true  of  the  diagnostic  field  of  neuro- 
syphilis, where  it  is  important  to  maintain  the  wow-paretic  hypo- 
thesis as  long  as  possible  in  the  interest  of  the  patient's  therapy. 

(e)  Opinions  might  differ  as  to  the  advisability  of  entertaining 
the  hypothesis  of  focal  brain  disease  before  or  after  the  hy- 
pothesis of   somatic    (non -neural)    disease  in  a  given    case.      The 


131 

pragmatic  rule  might  decide  one  way  for  general  hospital  clinics 
and  the  other  way  for  mental  clinics. 

(/)  Schizophrenia  should  be  eliminated  before  cyclothymia  on 
the  pragmatic  basis,  for  a  group  of  schizophrenic  symptoms  is 
much  more  decisive  for  dementia  prsecox  than  a  group  of  cyclo- 
thymic symptoms  is  decisive  for  manic-depressive  psychosis. 

(g)  The  pragmatic  method  decides  that  in  the  face  of  complete 
ignorance  of  its  true  nature,  involution-melancholia  is  better 
placed  in  the  cyclothymic  (manic-depressive)  group  than  in  the 
senile-senescent  group,  if  it  is  to  be  placed  in  either  group. 

Southaed,  E.  E.  Anatomical  Findings  in  the  Brains  of  Manic- 
depressive  Subjects.  This  paper  is  No.  99  (1915.2),  Con- 
tributions of  the  Massachusetts  Board  of  Insanity,  and  No. 
54,  Danvers-  State  Hospital  Contributions.  Some  of  the 
conclusions  were  presented  at  the  meeting  of  the  New 
England  Society  of  Psychiatry  at  Rutland,  Mass.,  in 
September,  1909.  An  abstract  was  presented  at  the  seven- 
tieth annual  meeting  of  the  American  Medico-Psychological 
Association  at  Baltimore,  May  26-29,  1914.  Proceedings, 
American  Medico-Psychological  Association,  Baltimore,  1914, 
XXI,  237-274. 

Conclusions. 

1.  Kraepelin  states  that  the  anatomy  of  manic-depressive  sub- 
jects is  negative.  Various  authors  have  described  focal  lesions 
with  which  to  account  for  the  occasional  dementia  which  text- 
books mention.  Evidence  as  to  the  existence  of  brain  stigmata 
is  equivocal.  Orton  has  recently  found  satellitosis  perhaps  rather 
more  in  manic-depressive  than  in  dementia-preecox  subjects. 

2.  The  fundamental  and  even  practically  important  question 
of  brain-anatomy  in  manic-depressive  subjects  has  been  here 
taken  up  precisely  with  the  same  ideas  and  with  similar  material 
as  in  the  writer's  first  study  of  dementia-prsecox  brains,  namely, 
with  the  topographic  idea  far  more  prominent  than  it  has  been 
made  by  most  workers  in  the  field  of  what  used  to  be  called 
"functional  psychoses." 

3.  The  first  question  which  occurs  to  a  critic  of  my  86  per  cent 
of  anomalies,  scleroses  and  atrophies  in  dementia  prsecox  is: 
What  percentage  of  similar  conditions  would  "not-insane"  sub- 
jects show,  and  what  would  be  shown  in  the  disease  manic- 
depressive  insanity?  The  present  paper  deals  with  the  latter 
inquiry  and  throws  indirect  light  upon  the  former. 


132 

4.  As  ever,  much  depends  upon  what  one  terms  manic-depres- 
sive psychosis.  In  the  text  I  have  given  relatively  full  accounts 
of  most  cases  excluded  from  my  initial  list,  which  comprised 
every  case  which  had  received  the  diagnosis  (at  times  on  de- 
cidedly insufficient  grounds)  in  a  certain  period  at  Danvers  Hos- 
pital. Many  of  my  exclusions  tend  to  swell  the  dementia-prsecox 
group,  and  these  cases  may  be  studied  with  my  dementia-prsecox 
material  of  1910.  To  avoid  confusion  I  have  excluded  cases  of 
involution-melancholia. 

5.  As  against  my  86  per  cent  lesions  in  dementia  prsecox,  I 
regard  13  per  cent  as  a  fair  percentage  for  manic-depressive 
insanity  (4  in  31).  A  little  less  rigorous  clinical  analysis  would 
leave  the  percentage  at  18  per  cent  (6  focal-lesion  cases  in  33). 
In  a  total  random  material  (after  certain  obvious  exclusions)  of 
38  cases,  it  would  not  be  possible,  I  believe,  for  the  most  ardent 
anatomist  to  find  more  than  11  cases  of  focal  lesions  (29  per 
cent).  But  this  last  percentage  is  assuredly  too  high,  since  three 
cases  in  the  group  are  pretty  clearly  cases  of  dementia  praecox. 
Thus  8  in  35  (23  per  cent)  is  a  figure  which  some  analysts  might 
prefer,  though  personally  I  believe  it  too  high. 

6.  Roughly  speaking,  then,  we  may  think  of  the  manic-depres- 
sive group  as  exhibiting  brain  stigmata  or  focal  lesions  {not  arterio- 
sclerotic) in  about  1  brain  in  every  5,  whereas  dementia-pr&cox 
brains   show   such   conditions   in   about   4   out  of  every  5   brains. 

7.  This  finding  must  be  of  some  significance,  whatever  the 
criteria,  and  whatever  particular  functional  correlations  one 
might  infer.  The  finding  does  not  prove  or  indicate  that  the 
manic-depressive  brain  is  normal,  but  it  does  show  that  the 
cellular  lesions,  if  any  are  to  be  found,  must  be  of  a  peculiar  and 
probably  a  reversible  nature.  And,  whereas  eager  histological 
researches  in  the  brain  are  much  to  the  point,  perhaps  the  canny 
observer  will  regard  the  non-nervous  organs  of  the  body,  or  those 
supplied  by  the  autonomic  system,  as  even  more  inviting  to  study 
in  the  manic-depressive  group. 

8.  No  special  histological  study  is  here  presented,  although 
some  orienting  slides  have  been  available  in  the  great  majority 
of  cases,  from  which  Orton's  conclusions  about  satellitosis  can 
be  in  a  measure  confirmed.  Indications  of  a  special  line  of  attack 
have  been  presented  by  Bond  in  a  paper  with  the  writer,  and 
some  conclusions  bearing  on  this  point  have  been  drawn  in  the 
writer's  thalamus  paper. 

9.  A  study  of  the  literature  yielded  a  few  special   questions 


133 

which  I  have  endeavored  to  answer,  largely  on  the  basis  of  the 
material  without  focal  lesions,  since  I  regard  these  four-fifths  of 
my  material  as  far  less  open  to  diagnostic  suspicion  than  the 
one-fifth  possessing  lesions. 

10.  The  question  of  the  relation  of  certain  instances  of  eventual 
dementia  to  arteriosclerotic  brain  lesions  is  provisionally  answered 
in  the  negative;    but  the  question  requires  further  study. 

11.  Heredity  does  not  show  itself  in  most  manic-depressives 
in  the  form  of  brain  stigmata;  but  the  extremely  high  index  of 
insane  heredity  in  near  relatives  is  remarkable.  I  am  inclined 
provisionally  to  regard  manic-depressive  insanity  as  constantly  or 
almost  constantly  hereditary,  not  in  the  sense  of  similar  heredity 
(this  has  not  been  adequately  studied),  but  in  the  sense  that 
some  kind  of  insanity  is  almost  always,  if  not  always,  to  be  found 
in  near  relatives.  Without  such  evidence,  I  am  clinically  not  now 
disposed  to  make  the  diagnosis  "manic-depressive,"  although  it 
is  clear  that  the  rule  will  not  work  in  the  other  direction.  For 
the  moment  I  am  challenging  my  records  to  produce  an  unexcep- 
tionable case  of  manic-depressive  psychosis  which  does  not  show 
family  taint  of  insanity. 

12.  Upon  these  provisional  hypotheses  are  we  to  assume  that 
the  normal-looking  brains  of  manic-depressives  are  really  normal, 
i.e.,  intrinsically,  and  merely  purveying  the  impulses  which  a 
sick  body  is  producing?  Or  shall  we  assume  a  chemical  or 
physicochemical  instability  of  the  entire  nervous  system,  such 
that,  although  the  brain  is  intrinsically  abnormal,  the  abnormality 
does  not  show  as  yet?  Hereditary  taint  is  consistent  enough 
with  either  assumption,  since  the  germ-plasm  might  with  equal 
readiness  mark  the  nervous  and  the  non-nervous  parts  of  the  body 
with  those  invisible  marks  that  produce  "functional  psychoses." 

Southard,  E.  E.  On  the  Direction  of  Research  as  to  the 
Analysis  of  Cortical  Stigmata  and  Focal  Lesions  in  Certain 
Psychoses.  Being  Contribution  of  the  State  Board  of  In- 
sanity, No.  42  (1915.8).  Transactions,  Association  of 
American  Physicians,  Philadelphia,  1914,  XXIX,  651-673. 

Summary  and  Conclusions. 

In  the  above  communication  I  have  endeavored  to  bring  out 

what   I   regard   as   an   important   line    of   structural   research   in 

mental   disease.      The   general  point   of   view   on  which   I   stand 

may  be  regarded  as  somatic,  although  the  topic  which  is  most 


134 

important  for  psychiatry  is  undoubtedly  the  functional  psychoses 
(especially  dementia  prsecox  and  manic-depressive  psychosis). 
In  dementia  prsecox  I  find  four-fifths  of  the  cases  showing  at 
autopsy  certain  appearances  which  may  be  regarded  as  anomalies 
or  lesions  in  some  sense.  Possibly  they  should  be  regarded  as 
weak  places  in  the  brain  structure  in  which  there  may  be  later 
every  evidence  of  progressive  disease.  The  percentage  of  cases 
of  dementia  prsecox  showing  these  lesions  is  80  per  cent  or  higher. 
The  percentage  in  the  brains  of  non-psychopathic  subjects  has 
never  been  properly  established,  but  in  the  so-called  functional 
mental  disease,  manic-depressive  psychosis,  I  find  similar  anom- 
alies or  lesions  in  about  20  per  cent  of  all  cases. 

Accordingly,  I  hold  that  dementia  prsecox  is  a  disease  in  which 
cortical  stigmata  are  much  more  often  found  than  in  certain 
other  forms  of  mental  disease,  and  probably  decidedly  more  often 
than  in  the  normal  citizens  of  the  world. 

The  direction  which  research  should  take  as  to  these  findings  is 
important.  My  point  of  view  here  is  again  a  structural  one.  I 
present  some  photographs  from  two  cases  which  indicate  what  I 
think  will  prove  a  rich  line  of  research.  There  are  two  main  lines 
of  consideration. 

First.  —  We  may  study  the  appearances  in  those  tissues  which 
are  regarded  as  the  sensory  arrival-platforms  of  the  cerebral-cortex 
(for  example,  the  calcarine  type  of  occipital  cortex)  and  contrast 
the  findings  in  the  sensory  arrival-platforms  with  findings  in  the 
elaborative  tissues  which  are  adjacent  thereto  (for  example,  the 
.common  occipital  type  of  cortex  in  the  occipital  region  just  men- 
tioned). It  is  currently  thought  that  we  can  safely  call  the  cal- 
carine type  the  visuo-sensory  type,  and  the  common  occipital 
type  the  visuo-psychic  part  of  the  cerebral-cortex.  When  we  are 
able  to  get  under  the  same  cover-glass  materials  fixed,  prepared 
and  stained  in  the  identical  manner  and  observable  in  the  same 
thickness,  we  are  undoubtedly  able  to  attach  much  consequence 
to  the  results  of  microscopic  examination. 

Second.  —  We  are  able  in  certain  cases  to  use  the  bilaterality 
of  structures  in  the  brain  to  help  us  in  our  interpretations.  I 
present  photographs  in  another  case  which  illustrate  the  line 
which  research  may  well  take.  One  post-central  gyrus  in  this 
case  was  about  half  the  thickness  of  the  other. 

The  interpretation  of  the  cell  richness,  the  possible  cell  losses 
and  the  nature  and  degree  of  neuroglia  cell  reaction  is  not  as  easy 
as  might  appear  at  first  sight.    Particularly  important  is  the  ques- 


135 

tion  of  the  form  of  neuroglia  cell  proliferation  which  is  variously 
termed  neuronophagia  and  satellitosis. 

In  the  present  argument  I  point  out  that  the  visuo-psychic 
tissues  of  a  certain  case  showed  satellitosis,  whereas  the  imme- 
diate adjacent  visuo-sensory  tissues  failed  to  do  so.  On  the  other 
hand,  I  find  that  the  narrow  and  apparently  decidedly  anom- 
alous postcentral  gyrus  of  another  case  fails  to  show  satellitosis, 
but  that  its  fellow  on  the  other  side,  showing  no  gross  lesion, 
shows  frank  evidences  of  satellitosis  when  examined  microscopi- 
cally. The  point,  perhaps,  is  that  the  narrow  gyrus  has  com- 
pleted its  pathological  evolution  and  has  passed  the  phase  of 
satellitosis;  but  our  results  here  must  remain  problematical  until 
we  know  more  as  to  the  intimate  nature  of  satellitosis. 

My  total  argument  for  a  certain  optimism  in  structural  re- 
search in  psychiatry  is  accordingly  founded,  not  upon  the  inter- 
esting clinical  correlations  of  the  two  cases  (A,  striking  scenic 
visual  hallucinosis,  satellitosis  of  common  occipital  cortex,  B, 
catatonic  phenomena  and  anomalies  of  the  postcentral  gyri),  but 
rather  upon  the  more  general  consideration  that  we  now  have, 
owing  to  the  efforts  of  the  modern  cortex  topographers,  the  basis 
for  differential  histopathological  analysis  of  adjacent  cortical 
tissues  of  different  functional  significance,  and  the  benefit  of 
examining  tissues  of  co-ordinate  nature  on  the  two  sides.  The 
careful  attention  of  the  histopathologist  in  the  nervous  system 
should  accordingly  be  given  to  all  those  planes  in  which  arrival- 
platform  tissue  comes  into  contact  with  higher  elaborative  tissues 
in  the  sense  of  the  modern  cortex  topographers;  and  the  findings 
in  any  gyrus  should  be  controlled  by  study  of  the  corresponding 
gyrus  of  the  other  hemisphere. 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  On  the  Nature 
and  Importance  of  Kidney  Lesions  in  Psychopathic  Sub- 
jects: A  Study  of  100  Cases  autopsied  at  the  Boston  State 
Hospital.  Being  Contribution  of  the  State  Board  of  Insanity,, 
No.  23  (1914.3).  Journal  of  Medical  Research,  Boston,, 
1914-15,  XXXI,  285-299.     (New  series,   Vol.   XXVI). 

Conclusions. 
1.  These  general  results  substantiate  those  of  a  more  super- 
ficial inquiry  in  a  larger  number  of  cases  (see  introductory  note) 
as  well  as  those  of  the  late  W.  L.  Worcester  on  the  same  kind  of 
material  (1899). 


136 

2.  The  inquiry  here  reported  deals  with  a  more  systematic 
histological  examination  of  kidneys  in  the  insane  than  has  been 
reported  for  many  years,  embodying  a  tabulation  of  findings  in 
the  gross  and  microscopically  in  the  different  recognizable  struc- 
tures of  the  kidney. 

3.  The  analysis  permits  saying  that  normal  kidneys  must  be 
of  the  greatest  rarity  in  the  insane  at  autopsy,  for  in  the  present 
series  of  100  no  instance  of  normal  kidneys  was  found. 

4.  It  is  less  possible  to  say  that  these  renal  conditions  were  of 
moment  to  the  individuals  who  bore  them,  since  some  of  the 
lesions  are  very  possibly  extinct,  and  others  cannot  safely  be  in- 
terpreted in  the  present  state  of  pathology. 

5.  Their  interest  from  the  therapeutic  and  dietetic  standpoint 
is  considerable,  since  there  were  at  least  39  instances  of  acute 
renal  disease,  and  11  of  these  complicated  by  a  background  of 
chronic  lesions. 

6.  Aside  from  these  39  acute  (or  acute  and  chronic)  conditions, 
there  were  55  instances  of  chronic  lesions  (or  66,  if  we  include 
the  11  cases  with  both  acute  and  chronic  lesions). 

7.  There  were  in  point  of  fact  but  5  cases  in  which  the  kidneys 
were  regarded  as  normal  to  the  naked  eye. 

8.  Clinically,  among  65  cases  examined,  albuminuria  was  found 
in  25  (or  38  per  cent),  and  cylindruria  in  18  (or  28  per  cent). 
Also  the  specific  gravity  went  below  1015  at  times  in  18  cases  (or 
28  per  cent).  No  special  statistical  significance  need  be  attached 
to  these  latter  figures. 

9.  Clinically,  also,  there  were  10  instances  of  oedema,  probably 
either  caused  or  favored  by  the  renal  condition  (4  of  these  10 
cases  showed  cardiac  disease  also). 

10.  Clinical  records  show  19  instances  of  seizures  or  convul- 
sions of  some  sort;  but  it  is  not  clear  how  many  of  these  can  be 
regarded  as  renal. 

11.  Clinical  records  also  indicate  that  23  of  the  100  cases  were 
regarded  in  life  as  more  or  less  severe  cardiac  cases. 

12.  Of  the  females  examined,  26  (or  52  per  cent)  had  borne  one 
or  more  children. 

13.  Thirty-two  of  the  100  cases  were  emaciated  at  death. 

14.  The  most  prominent  gross  lesion  in  the  series  was  chronic 
interstitial  nephritis,  which  occurred  in  42  cases. 

15.  Microscopically,  chronic  interstitial  nephritis  was  found 
not  only  in  these  42  cases,  but  also  in  24  other  cases  (a  total  per- 
centage of  66). 


137 

16.  There  were  33  cases  in  which  chronic  interstitial  nephritis 
was  not  only  marked  in  the  gross,  but  was  the  only  significant 
kidney  finding  microscopically  also. 

17.  Microscopically,  much  attention  was  paid  to  the  occurrence 
and  distribution  of  plasma  cells  in  the  kidney  substance,  since 
these  might  well  be  regarded  as  indicating  a  more  active  (or  less 
extinct)  sort  of  lesion  than  simple  fibrosis. 

18.  Plasma  cells  were  never  found  in  such  quantity  as  to  sug- 
gest acute  interstitial  nephritis,  but  plasma  cells  were  found  in 
42  per  cent  of  the  series. 

19.  Thirty-eight  of  these  42  plasma  cell  cases  showed  the 
plasma  cells  distributed  chiefly  about  the  glomeruli.  This  dis- 
tribution naturally  suggests  special  conditions  (toxic?)  in  the 
periglo.merular  region,  and  in  point  of  fact  there  was  very  fre- 
quently a  glomerular  lesion  associated  with  this  exudation. 

20.  A  broader  or  different  distribution  of  plasma  cells  was  far 
less  common,  and  the  small  groups  of  such  unusual  distribution 
are  presented  in  the  text. 

21.  Eleven  cases  out  of  26  under  fifty  years  of  age  yielded 
plasma  cells,  i.e.,  exactly  the  same  percentage  as  did  the  total 
series. 

22.  The  occurrence  of  plasma  cells  in  the  kidneys  of  general 
paretics  is  worthy  of  note  by  reason  of  their  constant  occurrence 
in  the  brains.  Seventeen  of  30  paretics  in  this  series  showed 
plasma  cells  in  the  kidney,  or  56  per  cent.  It  is  possible  that 
they  are  of  focal  occurrence  in  the  kidney  (though  nothing 
specially  to  indicate  this  was  found),  and  that  more  systematic 
work  would  swell  the  percentage.  Sixteen  of  the  17  paretics 
showed  the  plasma  cells  in  the  periglomerular  region,  while  1 
showed  them  in  a  subcapsular  zone. 

23.  Seven  of  the  whole  series  of  30  paretics  had  seizures;  5 
of  these  seizure  cases  showed  periglomerular  plasma  cells,  1 
showed  no  chronic  lesion  except  general  fibrosis,  and  1  was  a 
case  of  acute  parenchymatous  nephritis  without  chronic  lesion 
(12.13).  But  3  of  these  7  cases  showed  casts,  and  these  only  in 
one  tubule  type  (descending  loop  of  Henle). 

24..  Curiously  enough,  12  other  non-paretic  cases  which  had 
seizures  or  convulsions  of  various  sorts  failed  to  show  plasma  cells 
in  the  kidneys,  but  in  8  instances  did  show  casts,  although  always 
confined  to  a  single  tubule  type  (six  times  in  the  tubule  type  of 
election,  the  descending  loop  of  Henle). 
.25.  Seventy -three  cases  showed  casts  in  one  or  more  types  of 


138 

tubule;  50  cases  in  one  type  of  tubule  only  (40,  descending  loop 
of  Henle);  14  in  two  tubule  types;  7  in  three  tubule  types;  and 
2  in  four  tubule  types. 

26.  Sixty-three  of  the  73  cast-bearing  cases  showed  the  casts 
in  the  descending  loop  of  Henle,  which  seems  entitled  by  conse- 
quence to  be  called  the  tubule  of  election  for  cast  deposit  or  re- 
tention. 

27.  There  was  a  curious  time  distribution  of  those  cases  which 
showed  casts  in  the  less  common  locus  of  the  proximal  convoluted 
tubule.  Ten  of  these  12  cases  died  within  a  period  of  four 
months,  November  to  February,  1912-13.  One  may  suspect 
special  dietary  or  bacterial  conditions  for  this  fact. 

28.  Glomerular  tuft  changes  of  a  serious  nature  occurred  in  51 
cases,  and  there  were  indications  of  disease  in  13  others  (besides 
two  acute  lesions).  Changes  in  the  glomerular  capsule  were  far 
less  in  number,  being  of  a  serious  nature  in  but  17  cases  (slight  or 
infrequent  in  10  others).  Cast  deposits  occurred  in  8  cases  under 
fifty  years  of  age  without  evidence  of  glomerular  change. 

29.  Some  facts  are  noted  concerning  the  possible  relations  of 
acute  renal  lesions  to  infective  foci  in  the  urinary  apparatus  or 
in  the  body  at  large. 

30.  The  study  seems  to  show  a  significantly  high  proportion  of 
chronic  and  acute  lesions  of  the  kidney  in  psychopathic  subjects; 
such  conditions  should  engage  the  attention  of  dietitians  in  insane 
hospitals. 

Canavan,  Myrtelle  M.,  and  Southard,  E.  E.  The  Signifi- 
cance of  Bacteria  cultivated  from  the  Human  Cadaver: 
A  Second  Series  of  100  Cases  of  Mental  Disease,  with 
Blood  and  Cerebrospinal  Fluid  Cultures  and  Clinical  and 
Histological  Correlations.  Being  Contribution  of  the 
State  Board  of  Insanity  No.  24  (1914.4).  Journal  of 
Medical  Research,  Boston,  1914-15,  XXXI,  339-365. 
(New  series,  Vol.  XXVI.) 

Summary  and  Conclusions. 

(Note.  —  The  conclusions  have  been  numbered  to  correspond 
with  the  conclusions  of  Gay  and  Southard,  1910.) 

1.  In  a  study  similar  in  scope  to  that  of  Gay  and  Southard, 
1910,  the  writers  present  the  results  of  a  second  series  of  100 
bacterial   cultivations   from   the   heart's   blood   and   the   cerebro- 


139 

spinal  fluid  post  mortem  in  cases  of  mental  disease.     The  new 
series  is  from  the  Boston,  instead  of  the  Danvers,  State  Hospital. 

2.  The  bacteria  were  cultivated  upon  agar  plates  inoculated 
with  1.5  cubic  centimeters  heart's  blood,  and  others  with  1.5 
cubic  centimeters  cerebrospinal  fluid.  The  cerebrospinal  fluid  was 
removed  from  the  third  ventricle  through  the  infundibulum, 
severed  at  its  origin. 

3.  Forty-four  per  cent  of  the  blood  cultures  remained  sterile 
(Gradwohl,  22  per  cent;  Gay  and  Southard,  41  per  cent;  Otten, 
42  per  cent;    Simmonds,  48  per  cent). 

4.  Twenty-four  per  cent  of  the  cerebrospinal  fluid  cultures 
remained  sterile  (Tomlinson,  28  per  cent;  Gay  and  Southard,  28 
per  cent). 

5.  Under  somewhat  different  laboratory  conditions  the  Boston 
laboratory  (bodies  often  not  ice-cooled  and  always  held  at  a 
somewhat  higher  temperature  than  at  Danvers)  thus  paradoxi- 
cally yields  more  steriles  than  the  Danvers  laboratory  in  the 
blood  (44:41),  but  less  in  the  cerebrospinal  fluid  (24:28). 

6.  It  is  interesting,  however,  that  the  Boston-  series  shows 
fewer  cerebrospinal  positives  in  the  earlier  than  in  the  later 
periods  post  mortem,  —  a  tendency  quite  the  reverse  to  that  of 
the  Danvers  series,  where  the  icing  (often  freezing)  of  the  cada- 
vers may  well  have  inhibited  the  growth  of  bacteria  post  mortem. 

7.  On  the  other  hand,  the  heart's  blood  results  are  not  readily 
interpretable  on  the  above  or  any  other  basis,  unless  we  invoke 
special  bactericidal  properties  in  the  sera  of  different  cases. 

8.  With  the  lapse  of  time  post  mortem,  accordingly,  the  cere- 
brospinal fluid  certainly  seems  to  show  the  effect  of  its  non- 
bacteriolytic  properties  (see  conclusions  7-9  of  Gay  and  South- 
ard's article  quoted  above),  at  a  comparatively  early  date,  in  the 
increased  frequency  of  its  positives  when  temperature  permits 
(Boston)  as  against  no  increased  frequency  (or  reduction?)  when 
temperature  is  unfavorable  (Danvers). 

9.  The  heart's  blood  with  its  (for  some  time)  persistent  bac- 
teriolytic substances  does  not  seem  to  show  notable  variation  in 
its  incidence  of  positives  as  time  post  mortem  elapses  under 
either  Boston  or  Danvers  conditions. 

10.  As  to  particular  bacterial  forms,  cocci  prevail  in  both 
series,  and  in  both  series  there  were  more  cultivations  of  cocci 
from  the  cerebrospinal  fluid  than  from  the  blood. 

11.  At  Danvers  no  diphtheroid  organisms  were  picked  up  in 
bodies  of  paretics  (pace  Ford  Robertson,  1906);    at  Boston  there 


140 

was  one  such  instance  from  the  blood  and  fluid  of  a  case.  This 
as  well  as  other  considerations  concerning  secondary  invasions  in 
general  paresis  will  be  taken  up  in  a  separate  communication. 

12.  Cultivations  from  twenty-six  general  paretics  are  listed; 
cocci  no  longer  especially  prevail  in  the  positive  cases  (contra 
Dan  vers). 

13.  No  conclusion  as  to  the  possible  relation  of  bacterial  in- 
vaders to  fatty  changes  can  be  drawn  from  the  sterile  cases,  since 
all  the  cases  but  one  were  too  old  to  be  free  from  the  suspicion 
of  age-changes  in  the  production  of  lipoid  alterations;  there  was, 
however,  one  case,  twenty-three  years  of  age,  probably  quite 
sterile  throughout,  and  this  case  showed  no  lipoid  alterations  in 
any  part  studied. 

14.  On  the  other  hand,  there  were  twenty  cases  in  which  no 
fatty  changes  were  found  histologically,  and  of  these  no  case 
showed  Bacillus  coli  communis,  and  cocci  prevail  as  in  the 
Danvers  series.  Thus,  whether  we  assume  various  lipoid  altera- 
tions to  go  on  ante  mortem  or  post  mortem,  and  under  the  in- 
fluence of  bacteria  or  not  under  such  influence,  it  would  appear 
that  cocci  can  hardly  be  charged  with  effecting  such  lipoid 
changes. 

15.  Forty-six  cases  are  listed,  having  had  symptoms  less  than 
four  days  in  duration,  as  against  31  in  the  Danvers  series;  18 
per  cent  of  the  new  series,  examined  by  fat-staining  methods, 
proved  negative  as  against  29  per  cent  histologically  negative  in 
the  Danvers  series;  and  the  18  per  cent  thus  both  clinically  and 
histologically  negative  in  the  Boston  series  contrast  with  14  per 
cent  histologically  negative  in  the  total  Boston  series,  —  a  varia- 
tion in  the  same  direction  as  in  the  Danvers  series  (29  per  cent: 
10  per  cent),  only  less  striking. 

16.  In  8  cases  chosen  as  showing  most  marked  fatty  changes 
there  were  no  instances  of  colibacillosis  (one  case  only  of  anaero- 
genes  bacillemia);  in  fact,  5  cases  were  negative  in  the  cerebro- 
spinal fluid,  and  6  negative  in  blood. 

17.  One  of  the  highly  (Marchi)  degenerated  cases  (among  the 
8  just  mentioned)  yielded  Cladothrix  invulnerabilis  in  the 
cerebrospinal  fluid;  a  second  case  with  the  same  finding  also 
showed  degeneration,  though  of  less  marked  degree;  two  of  the 
highly  degenerated  cases  (of  the  8  supra)  yielded  Bacillus  muri- 
septicus;    another  case  showed  degenerations,  but  less  marked. 

18.  There  were  9  cases  of  generalized  softening  of  brain  tissues 
in  the  Boston  series  as  opposed  to  13  in  the  Danvers  series;  more- 


141 

over,  three  of  these  Boston  cases  were  autopsied  from  three  to 
eight  and  one-half  days  post  mortem  (at  a  time  when  ferment 
action  may  be  presumed  to  be  under  way).  No  case  showed 
Bacillus  coli  communis;  the  bacteria  found  were  in  two  instances 
reputed  pathogens  (Bacterium  varicosum  and  Micrococcus  sali- 
varius).  In  three  other  cases  the  organisms  were  either  liquefiers 
of  various  media  (Bacillus  subtilis,  Micrococcus  alvi)  or  ab- 
stractors of  water  (Cladothrix  invulnerabilis).  In  only  one  case 
was  the  bacteriology  negative  (a  case  of  ulcerative  colitis). 

19.  Only  indirect  evidence  concerning  the  effect  of  Bacillus  coli 
communis  or  its  toxines  on  nerve  fiber  degeneration  is  here 
afforded;  however,  the  organisms  which  are  associated  with  the 
soft  brains  in  the  Boston  series  are  in  most  cases  also  liquefiers  of 
various  laboratory  media. 

Epicritical  Conclusions.  —  The  conclusions  of  the  new  study  in 
general  coincide  with  those  of  Gay  and  Southard,  but  present 
some  novel  points  (especially  conclusions  6,  8,  14,  16,  18),  and 
these  points  may  be  briefly  considered  as  follows:  — 

20.  It  is  suggested  by  a  comparison  of  the  two  series  that  the 
more  immediate  and  thorough  cooling  (or  even  icing)  of  the 
Danvers  cadavers  has  served  to  inhibit  the  growth  of  bacteria  in 
the  cerebrospinal  fluid,  since  the  lapse  of  time  post  mortem  is 
attended  in  the  Boston  series  by  increasing  frequency  of  positives 
in  the  cerebrospinal  fluid. 

21.  The  blood  findings  show  no  such  effects  as  those  just  men- 
tioned for  the  cerebrospinal  fluid;  perhaps  the  curve  is  spoiled  by 
the  presence  or  absence  in  special  cases  of  bactericidal  sub- 
stances in  the  blood. 

22.  Whatever  may  be  said  of  the  possible  ante-mortem  or 
post-mortem  effects  of  other  organisms  in  producing  lipoid 
changes  in  the  nervous  system,  the  cocci  as  a  group  may  be  ab- 
solved from  this  charge;  if  the  cocci  act  at  all  ante  mortem,  it 
must  be  rather  in  the  direction  of  irritative  than  of  destructive 
effects. 

23.  The  absence  of  colibacillosis  in  the  Boston  series  is  striking; 
a  few  other  organisms,  either  pathogenic  or  somewhat  destructive 
to  the  laboratory  media  used  for  their  cultivation,  enter  to  take 
the  place  of  Bacillus  coli  communis  in  the  "soft  brain"  cases. 


142 


1915. 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  A  Study  of 
Normal-looking  Brains  in  Psychopathic  Subjects:  Third 
Note  (Boston  State  Hospital).  Being  Contribution  of  the 
State  Board  of  Insanity,  No.  35  (1915.1).  Boston  Medical 
and  Surgical  Journal,  1915,  CLXXII,  124-131. 

Conclusions. 

1.  The  present  is  a  fragment  from  more  extensive  studies 
tending  to  settle  the  question  how  far  mental  disease  is  consistent 
with  normality  of  brain;  and  as  in  previous  work  from  the 
Worcester  State  Hospital,  so  this  work  from  the  Boston  State 
Hospital  has  chosen  to  begin  with  normal-looking  brains,  since 
these  are  more  likely  to  be  essentially  normal  than  those  brains 
which  yield  obvious  lesions. 

2.  On  comparison  with  the  Worcester  percentage  of  normal- 
looking  brains,  viz.,  about  1  in  3,  and  the  Danvers  percentage, 
viz.,  about  1  in  4,  the  present  Boston  percentage  is  much  lower, 
viz  ,  about  1  in  8. 

3.  We  do  not  deny  that  some  of  the  lesions  found  in  the 
abnormal  brains  may  have  had  little  or  nothing  to  do  with  the 
mental  disease  which  their  bearers  showed;  the  point  of  our 
research  lodges  in  the  endeavor  to  discover  essentially  normal 
brains  in  subjects  of  mental  disease.  There  are  20  in  153 
examined  by  uniform  methods  which  gave  promise  of  being 
microscopically  as  well  as  macroscopically  normal. 

4.  One  normal-looking  brain  yielded  a  chronic-looking  exu- 
date, Case  I  (12.55)  which  was  a  case  of  general  paresis  of  brief 
duration  (less  than  five  months),  clinically  certain,  showed 
nerve  cell  and  fibre  changes,  gliosis  and  perivascular  mononu- 
cleosis (including  plasma  cells)  of  fairly  even  degree  throughout 
sections  examined.  The  gross  examination  yielded  opaque  points 
of  thickening  in  the  pia  mater  over  the  vertex.  The  dura  had 
begun  to  thicken  and  the  calvarial  diploe  had  begun  to  disappear. 
The  brain  had  not  lost  more  than  100  grams  in  weight  (Tigges' 
formula). 

5.  One  case  yielded  evidences  of  acute  perivascular  exudate 
post-pneumonic  encephalitis,  but  the  mental  picture  cannot  be 
regarded  as  due  to  the  exudate. 

6.  The  suspicion  is  often  uttered  that  cases  not  infrequently 
show  fine  vascular  disease  not  evident  in  the  gross.     No  such 


143 

case  has  appeared,  but  there  was  one  (X,  11.42)  which,  despite 
coarse  changes  in  the  basal  vessels,  was  included  in  the  normal- 
looking  series  and  microscopically  showed  slightly  marked  fine 
vascular  changes  with  equally  marked  cortical  changes  (no  in- 
farcts, but  generalized  and  focal  losses).  This  case  was  a  female 
of  eighty  whose  brain  weighed  1,125  grams,  i.e.,  5  grams  above 
the  calculated  weight  according  to  body  length.  It  is  possible 
that  the  brain  was  slightly  edematous  —  vacuoles  among  nerve 
cells  (eighteen  hours  post  mortem,  tuberculous  peritonitis).  The 
brain  was  included  in  the  normal-looking  series,  although  on  the 
autopsy  table  the  diagnosis  of  "general  cerebral  gliosis"  was 
made  (confirmed  by  the  excess  of  cells  in  the  plexiform  layer  in 
virtually  every  region  examined).  It  may  be  inquired  why  a 
case  with  basal  vascular  disease  should  not  be  forthwith  excluded 
on  the  ground  that  fine  changes  will  be  certain  to  be  found;  but 
they  are  not  sure  to  be  found,  as  XIV,  12.11,  proved  (since  in 
this  case  there  were  gross  arterial  changes  and  few  or  no  fine 
vascular  changes). 

7.  We  have  accordingly  reduced  our  20  normal-looking  cases  to 
18,  which  still  give  some  promise  of  proving  normal  on  microscopic 
examination.  One  of  these  18  was  a  case  of  epilepsy,  V,  11.26, 
with  dementia;  and  since  the  epilepsy  began  in  infancy,  it  is  doubt- 
ful whether  it  should  be  included  in  this  study.  Microscopically, 
in  any  event,  there  were  numerous  evidences  of  cell  losses. 

8.  If  we  exclude  this  case  of  epilepsy  from  the  normal-looking 
numerator  of  the  fraction,  we  should  also  possibly  exclude  5 
other  epileptics  (or  in  all  6)  from  the  denominator,  yielding  a 
percentage  of  11.5,  i.e.,  17  in  147  cases,  excluding  all  epileptics 
and  two  cases,  I  and  X,  in  which  the  microscope  revealed  changes 
which  should  theoretically  yield  gross  lesions. 

9.  In  a  study  of  the  percentage  of  normal-looking  brains  it 
would  be  wise,  also,  to  exclude  clear  cases  of  imbecility,  of  which 
there  were  2  in  the  series,  neither  of  which  yielded  a  normal- 
looking  brain;  this  makes  a  percentage  of  11.7  per  cent  normal- 
looking  brains  in  a  series  of  145. 

10.  In  the  analysis  of  this  residue  of  17  normal-looking  brain 
cases  we  must  first  consider  the  question  of  atrophy  or  aplasia. 
Eleven  cases  yielded  brain  weights  above  normal,  employing 
Tigges'  formula  (i.e.,  8  X  body  length  in  cm.  =  probable  brain 
weight).  Six  remaining  brains  weighed  less  than  normal  accord- 
ing to  this  formula.  Of  these  6,  one  (Case  IV,  11.11)  yielded 
a  brain  weight  of  1,010  grams,  calculated  weight,   1,208  grams, 


144 

which  should  probably  make  this  case  fall  into  the  atrophic 
brain  group.  The  reflex  picture  and  certain  other  clinical  features 
gave  rise  to  the  diagnosis  taboparesis.  The  total  duration  was 
but  one  month  and  four  days.  The  absent  knee  jerks  proved 
due  either  to  axonal  anterior  horn  cell  reactions  or  to  peripheral 
neuritis  (abundant  Marchi  degenerations),  and  it  is  probable  that 
we  are  dealing  with  a  Korsakoff' s  psychosis  (history  of  previous 
attacks  of  alcoholic  mental  disease  not  obtained,  but  possible). 
Abundant  evidence  of  cell  loss  with  satellitosis  was  found  in 
many  areas  microscopically. 

11.  Another  case  (XV,  12.29)  yielded  a  brain  weighing  1,050 
grams,  i.e.,  a  calculated  loss  of  150  grams.  This  case  showed 
various  evidences  of  atrophy  in  other  organs  also,  and  microscop- 
ically a  remarkably  diffuse  cell  loss  in  the  cortex.  Clinically 
the  case  was  one  of  involution-melancholia,  fifty-nine  years  of 
age,  of  twenty  months  and  fourteen  days. 

12.  Case  XIII,  11.5,  with  a  calculated  brain  weight  loss  of 
120  grams,  was  a  female  of  seventy-three  years,  with  total  dura- 
tion of  about  eight  years.  The  microscopic  evidences  of  cell 
loss  were  such  that  this  case  also  must  probably  be  placed  in  the 
atrophic  group;  in  point  of  fact,  her  brain  atrophy  was  probably 
obscured  by  increase  of  weight  eight  and  one-half  days  post 
mortem  (brain  not  palpably  soft  on  account  of  gliosis). 

13.  Case  XIX,  10.9,  with  a  calculated  brain  weight  loss  of 
100  grams,  showed  a  small  heart  (145  grams)  and  a  small  liver 
(1,000  grams).  This  case  probably  does  not  belong  in  the 
atrophic  group,  since  microscopically  there  was  small  evidence 
of  cell  loss.  This  case  of  paranoid  dementia  prsecox  will  be 
considered  below.  Case  XVI,  11.36,  and  Case  XII,  13.41,  with 
calculated  brain  weight  losses  of  76  and  54  grams,  respectively, 
can  also  hardly  be  classed  as  showing  important  degrees  of  brain 
atrophy  (see  below). 

14.  One  case  (VII,  11.31)  must  be  excluded  from  the  present 
analysis,  because  total  brain  sections  are  in  process  of  making 
(case  of  syringomyelia). 

15.  There  remains  a  group  of  12  cases,  excluding  I,  XIV,  V 
from  the  original  19,  i.e.,  I  as  general  paretic,  XIV  as  arterio- 
sclerotic dement,  V  as  epileptic,  IV,  XV  and  XIII  as  having 
atrophic  brains,  VI  as  syringomyelia  (analysis  unfinished).  We 
accordingly  remain  with  1  normal-looking  brain  in  12. 

16.  The  residue  of  normal-looking  brains,  with  the  above  8 
omissions,  consists  of  the  following  12:  — 


145 


Case. 

II  (13.44)       . 

III  (13.6)       . 

VIII  (12.37) 

IX  (13.16)     . 

XI  (12.7)      . 

XII  (13.41)  . 
XIV  (12.11) 

XVI  (11.36) 

XVII  (13.29) 

XVIII  (13.7) 

XIX  (10.9)  . 

XX  (12.47)  . 


Sex. 

F. 
M. 
F. 
M. 
M. 
F. 
M. 
F. 
F. 
F. 
F. 
F. 


Age. 

44 
44 
71 
77 
43 
60 
84 
30 
53 
64 
56 
27 


Onset. 

44 
43 
71 

75 
42 
50 
67 
29 
41 
20 
42 
25 


Duration. 

y/z  mos. 

V/%  mos. 

8  mos. 

22  mos. 

3  mos. 

10%  yrs. 

14  yrs. 

20  mos. 

13^  yrs. 

2  -M^  yrs. 

14  yrs. 

28  yrs. 


Diagnosis. 

Central  neuritis. 

General  paresis  ?    Korsakoff. 

Senile  psychosis. 

Senile   psychosis;   cerebral   arte- 
riosclerosis. 
Exhaustion  psychosis. 

Unclassified  (paranoia). 

Involution-melancholia. 

Manic-depressive  psychosis. 

Manic-depressive  psychosis. 

Unclassified  manic  depressive. 

Paranoia  or  dementia  prsecox. 

Dementia  prsecox  (catatonia). 


17.  Attention  is  first  directed  to  four  cases  of  mental  disease 
over  ten  years  in  duration;  these  are  XIX,  XIV,  XII  and 
XVII. 

18.  This  group  of  cases  in  which  gross  registration  of  lesions 
might  have  been  expected  was  subjected  to  orienting  microscopic 
examination:  — 

Case  XIX,  10.9,  shows  strikingly  few  evidences  of  cell  loss, 
but  careful  search  discovered  foci  of  cell  loss  in  the  right  second 
temporal  gyrus.  This  case,  though  of  slow  evolution  and  diagnos- 
ticated paranoia,  is  thought  to  have  had  hallucinations  of  hearing 
as  well  as  of  sight.  The  delusions  were  largely  of  jealousy  and 
otherwise  sexual.  One  attack  of  so-called  "cerebral  congestion" 
at  forty. 

Case  XIV,  12.11,  involution-melancholia,  eighty-four  years  at 
death,  exhibited  considerable  cell  loss  in  outer  layers  without 
marked  satellitosis.     Marked  cell  loss  in  calcarine  region. 

Case  XII,  13.41,  unclassified  paranoic  case,  died  at  sixty, 
showed  fairly  numerous  cell  losses. 

Case  XVII,  13.29,  manic-depressive  psychosis,  died  at  fifty- 
three,  showed  numerous  cell  losses,  especially  in  upper  layers. 

19.  According  to  a  principle  mentioned  in  the  Worcester  analy- 
sis, it  would  be  unlikely  that  induration  should  register  itself  in 
brains  undergoing  gliosis  in  less  than  three  months.  There  were 
three  cases  (II,  III,  XI)  of  which  II  was  the  case  of  possible 
central  neuritis  with  marked  acute  cell  changes  ample  to  explain 
roughly  the  brief  mental  disease;   III  showed  numerous  acute  cell 


146 

changes,  probably  quite  consistent  with  the  mental  picture 
(Korsakoff's  psychosis);  and  XI  showed  cell  losses,  perhaps  of 
long  standing  (although  there  were  overt  symptoms  for  three 
months  only),  together  with  acute  cell  changes. 

20.  The  group  of  intermediate  duration,  three  months  to  three 
years,  comprises  5  cases,  —  XVI,  VIII,  XX,  XVIII,  IX.  Of 
these,  VIII,  aged  seventy-one,  and  IX,  aged  seventy-seven, 
attract  attention  on  the  score  of  age.  Both  showed  cell  losses: 
in  the  former,  focal  with  perivascular  gliosis;  in  the  latter, 
marked  diffuse  losses.  Of  the  three  remaining,  two  are  manic- 
depressive  cases  (XVI,  11.36,  and  XVIII,  13.7),  and  one  (XX), 
catatonic  dementia  prsecox.  All  three  showed  moderate  degrees 
of  cell  loss. 

21.  Accordingly,  it  is  plain  that  the  search  for  functional 
psychoses  which  shall  be  above  all  neuropathological  reproach  is 
an  exceedingly  elusive  task,  and  possibly  never  to  be  rewarded. 
In  a  forthcoming  communication  we  shall  deal  with  the  detailed 
microscopic  picture  in  five  of  the  cases  of  this  series  (XII,  XVI, 
XVIII,  XIX,  XX),  since  these  five  appear  to  be  the  least  likely 
of  all  our  series  of  153  cases  to  show  important  microscopic 
lesions. 

Southard,  E.  E.  Some  Relations  of  Mania  to  the  Sensorium. 
(Abstract.)  Psychological  Bulletin,  Lancaster,  Pa.,  and 
Princeton,  N.  J.,  1915,  XII,  73. 

Remarks. 
Mania,  as  conceived  by  modern  workers,  tends  always  to  entail 
what  Wernicke  has  called  hyperkinesis.  It  might  be  natural  to 
seek  for  the  sources  of  hyperkinesis  in  the  kinetic  brain  mecha- 
nisms. In  point  of  fact,  however,  various  better-known  condi- 
tions of  hyperkinesis,  such  as  epilepsy  and  chorea,  are  often  found 
related  with  lesions  in  various  parts  of  the  sensorium,  and  may 
even  require  a  certain  integrity  of  the  kinetic  apparatus.  A  brief 
review  is  given  of  the  writer's  work,  showing  the  relations  of 
hyperkinetic  symptoms  to  certain  lesions  of  the  optic  thalamus. 
New  work  is  adduced  concerning  the  association  of  mania  with 
irritative  lesions  of  the  hinder  part  of  the  cerebral  cortex  (senso- 
rium). Some  other  arguments  are  presented  for  the  sensorial 
origin  of  hyperkinetic  symptoms,  and  for  the  peculiar  value  of 
the  intaking  nervous  mechanisms  for  the  so-called  behavior- 
psychology. 


147 

Southard,  E.  E.,  and  Canavan,  Myrtelle  M.  Notes  on  the 
Relations  of  Somatic  (Non-Neural)  Neoplasms  to  Mental 
Disease.  (From  the  Psychopathic  Hospital  Laboratory  of 
the  State  Board  of  Insanity  (1915.11.))  Interstate  Medical 
Journal,  St.  Louis,  1915,  XXII,  738-751. 

Summary  and  Conclusions.  * 

The  writers  present  a  sketchy  review  of  the  present  relations  of 
tumor  research  to  psychiatry,  pointing  out  the  special  value  of 
teratological  conclusions  and  brain  tumor  work  to  psychiatry. 
The  writers  wish  all  brain  tumor  cases  carefully  examined  by 
psychiatrists  to  be  published  for  the  purpose  of  corroborating  or 
modifying  the  conclusions  of  Schuster  as  to  correlations  between 
tumors  in  various  brain  parts  and  mental  symptoms.  Reference 
is  made  to  recent  work  on  symptomatic  psychoses  and  to  various 
other  pieces  of  work  showing  the  close  relation  of  oncology  to  psy- 
chiatry as  found  in  the  volumes  of  Zeitschrift  fur  Krebsforschung. 

The  writers  believe  that  less  than  3  per  cent  of  routine  autopsy 
material  of  State  hospitals  for  the  insane  will  show  tumors  of 
the  brain.  The  figures  for  non-neural  tumors  stand  at  3.9  per 
cent;  allowing  for  errors  and  omissions  of  diagnosis,  4  per  cent 
may  be  given  as  a  roughly  approximate  index  of  the  number  of 
non-neural  tumors  in  insane  hospital  autopsies.  It  is  clear,  ac- 
cordingly, that  brain  tumors  are  of  some  importance  in  the  causa- 
tion or  liberation  of  mental  symptoms.  Special  lists  are  made  of 
20  gastric  carcinomata,  6  intestinal,  10  uterine  and  6  mammary 
occurring  in  the  Boston  and  Danvers  series.  A  study  of  mental 
symptoms  displayed  by  cases  possessing  or  developing  non-neural 
neoplasms  has  been  made,  from  which  it  is  clear  that  certain 
symptoms  stand  higher  and  lower  than  they  do  in  mental  dis- 
eases at  large.  For  example,  incoherence  stands  high  in  these 
cases,  emphasizing  the  frequency  of  delirium  in  the  group.  De- 
pression, on  the  other  hand,  which  has  frequently  been  stated  to 
be  a  major  symptom  in  cases  of  intestinal  disease,  stands  low  in 
the  cancer  list,  although  it  stands  exceedingly  high  in  a  list  of 
symptoms  derived  from  17,000  living  and  dead  cases  (Danvers 
State  Hospital).  The  symptom  sicchasia  (refusal  of  food),  com- 
paratively low  in  the  17,000  miscellaneous  cases,  stands  out 
prominently  in  carcinoma  cases.  Insomnia  is  surprisingly  low  in 
the  psychopathic  cancer  group.  Pain  is  not  at  all  frequent  in 
these  cases.  Cancer  cases  seem  to  have  shown  a  marked  exhi- 
bition of  delusions  with  respect  to  food  and  with  respect  to  mem- 


148 

bers  of  the  family.  The  ideational  reactions  to  the  world  of  these 
cancer  cases  are,  on  the  whole,  of  an  unpleasant  nature,  despite 
the  comparative  infrequency  of  depression. 

The  writers  present  7  cases  in  which  it  might  be  thought  that 
the  cancers  had  close  relation  to  the  development  of  mental 
symptoms.  Two  of  these  are  from  the  Psychopathic  Hospital, 
Boston,  one  of  which  (Case  VI)  is  most  suggestive;  but  even 
in  Case  VI  there  were  brain  lesions  of  an  acute  nature,  which 
may  have  complicated  the  picture.  The  second  Psychopathic 
Hospital  case  (Case  VII)  was  one  in  which  the  pancreatic 
carcinoma  with  its  metastases  may  perhaps  decidedly  have 
influenced  the  symptoms  in  the  fatal  attack,  but  the  casa  can 
be  demonstrated  to  have  been  decidedly  psychotic  at  the 
outset. 

The  remaining  5  cases  (Cases  I  to  V)  are  from  the  Danvers  and 
Boston  series.  The  correlations  in  Case  I  are  fairly  close  in  point 
of  time  and  in  simultaneous  occurrence  of  physical  signs  of  gastric 
cancer.  The  correlations  in  Case  II  are  somewhat  suggestive, 
and  the  hypochondriacal  delusions  ("stomach  full")  are  striking. 
Two  cases  of  esophageal  carcinoma  appear  to  illustrate  the 
general  tendency  of  carcinoma,  or  infection  derived  therefrom, 
to  produce  delirium  or  phenomena  of  the  "exhaustion"  group 
of  the  psj^chiatrists.  Case  V  was  a  case  of  toxic  delirium,  ap- 
parently somewhat  closely  related  to  developments  in  a  sarcoma 
of  the  jaw.  The  correlation  is  very  possibly  between  infection 
from  ulcer  and  mental  symptoms. 

Out  of  68  cases  of  non-neural  tumor  found  in  the  Boston  and 
Danvers  series,  some  16  might  be  thought  to  show  possible 
oncogenesis  of  the  mental  symptoms.  A  study  of  these  16  cases 
quickly  shows  that  the  5  enumerated  above  were  the  only  ones 
in  which  the  correlation  was  at  all  convincing.  The  cases  in 
question  show  phenomena  possibly  related  to  infection  of  ulcera- 
tive cancer  surfaces,  with  some  instances  of  a  delusional  coloring 
related  to  the  tumors. 

On  the  whole,  accordingly,  there  cannot  at  present  be  erected  a 
very  persuasive  argument  for  the  oncogenesis  of  mental  disease, 
but  certain  mental  symptoms  may  possibly  be  altered  by  car- 
cinoma. In  one  instance  (Case  VI),  a  Psychopathic  Hospital 
case,  the  predominance  of  neurological  symptoms  in  the  vagus 
region  of  supply  directed  attention  to  the  probability  of  the 
gastric  carcinoma  found  at  autopsy. 


149 

Southard,  E.  E.  General  Psychopathology.  Psychological 
Bulletin,  Princeton,  N.  J.,  and  Lancaster,  Pa.,  1915,  XII, 
245-273. 

Southard,  E.  E.  Data  concerning  Delusions  of  Personality, 
with  Note  on  the  Association  of  Bright's  Disease  and  Un- 
pleasant Delusions.  Presented  in  abstract  at  the  sixth 
annual  meeting  of  the  American  Psychopathological  Asso- 
ciation, held  in  New  York  City,  May  5,  1915.  Being  Con- 
tribution of  the  State  Board  of  Insanity  No.  47  (1915.13). 
The  material  was  derived  from  the  pathological  laboratory 
of  the  Danvers  State  Hospital,  Hathorne,  Mass.,  and  the 
clinical  notes  were  collected  by  Dr.  A.  Warren  Stearns, 
to  whom  I  wish  to  express  my  indebtedness,  but  to  whom 
no  one  should  ascribe  the  somewhat  speculative  character  of 
the  present  conclusions.  Journal  of  Abnormal  Psychology, 
Boston,  1915,  X,  241-262. 

Summary  and  Conclusions. 

The  paper  deals  with  delusions  of  a  personal  (autopsychic) 
nature,  and  is  one  of  a  series  based  upon  certain  statistics  of  Dan- 
vers State  Hospital  cases  (previous  work  published  on  somatic, 
environmental  (allopsychic)  delusions  and  those  characteristic  of 
general  paresis).  The  previous  work  had  suggested  that  somatic 
delusions  are  perhaps  more  of  the  nature  of  illusions  in  the  sense 
that  somatic  bases  for  somatic  false  beliefs  are  as  a  rule  found. 
On  the  other  hand,  delusions  respecting  the  environment  (allo- 
psychic delusions)  had  appeared  to  be  more  related  to  essential 
disorder  of  personality  than  to  actual  environmental  factors. 

The  fact  that  cases  of  paresis  with  delusions  were  found  to 
have  their  lesions  in  the  frontal  lobe,  whereas  non-delusional 
cases  showed  no  such  marked  lesions,  is  of  interest  in  the  light  of 
the  present  paper,  because  three  cases  of  senile  psychosis  were 
found  to  have  delusions  of  grandeur  and,  although  they  are 
demonstrably  not  paretic,  they  also  show  mild  frontal  lobe 
changes  supported  by  microscopic  study. 

The  Danvers  autopsied  series,  containing  1,000  unselected 
cases,  was  found  to  show  306  instances  with  little  or  no  gross 
brain  disease.  Of  these,  106  had  autopsychic  delusions,  and  of 
these  106,  50  cases  had  delusions  of  no  other  sort;  15  of  these 
50  cases  appeared  to  have  been  cases  of  general  paresis  in  which 
gross    brain    lesions    were   not    observed   at   autopsy,    and    upon 


150 

investigation  13  other  cases  were  found  to  be,  for  various  reasons, 
improperly  classified.  The  residue  of  22  cases  was  subject  to 
analysis,  and  readily  divides  itself  into  two  groups  of  11  cases 
each,  or  two  groups  of  normal-looking  brain  cases  having  auto- 
psychic  delusions;  and  these  only  are  cases  which  may  be 
termed  the  "pleasant"  and  "unpleasant"  groups,  in  the  sense 
that  the  delusions  in  the  first  group  were  either  pleasant  or  not 
unpleasant,  whereas  the  delusions  in  the  second  group  were  of 
clearly  unpleasant  character. 

Three  of  the  "pleasant"  delusion  group  were  the  three  cases 
of  grandeur  and  delusions  in  the  senium  above  mentioned.  Three 
others  were  cases  of  "theomania"  in  the  sense  that  their  delu- 
sions concerned  messages  from  God.  It  is  not  clear  that  these 
three  religious  cases  should  be  regarded  as  belonging  in  the  group 
of  "pleasant"  delusions  on  account  of  the  sense  of  constraint 
felt  by  the  patients. 

The  remainder  of  the  "pleasant  group,"  as  the  delusions  were 
originally  defined,  turned  out  for  the  most  part  to  show  either 
doubtful  delusions  or  delusions  involving  a  sense  of  constraint 
rather  than  of  pleasure. 

An  endeavor  was  made  to  learn  the  relations  of  pulmonary 
phthisis  to  the  emotional  tone  of  the  delusions.  The  few  avail- 
able cases  in  this  series  seem  consistent  with  the  hypothesis  of 
phthisical  euphoria  (IV,  "happiest  woman  in  the  world,  hearing 
God's  voice,"  VII  and  possibly  XI). 

The  problems  of  the  "pleasant"  delusion  group,  as  superficially 
defined,  turned  out  to  be  (a)  the  problem  of  a  group  of  senile 
psychoses  with  grandiose  delusions  and  frontal  lobe  atrophy;  (6) 
the  problem  of  felt  passivity  under  divine  influence;  (c)  the  prob- 
lem of  phthisical  euphoria. 

The  group  of  "unpleasant"  delusions  in  the  normal-looking 
brain  group  should  be  diminished  by  one  on  account  of  its  positive 
microscopy  (encephalitis).  One  case  (XIII)  is  a  case  of  mixed 
emotions  of  religious  type,  showing  phthisis  pulmonalis,  together 
with  abdominal  tuberculosis  and  nephritis.  One  case  (XV)  is 
doubtful  as  to  delusions;  the  remainder  are  subject  to  renal  dis- 
ease, as  a  rule  associated  with  cardiac  lesions. 

Two  cases  which  were  transferred  from  the  "pleasant"  to  the 
"unpleasant"  group  on  account  of  constraint  feelings  were  also 
renal  cases,  —  VII  and  IX.  The  only  exception  to  the  universal- 
ity of  renal  lesions  in  this  group  is  the  case  in  which  religious 
delusions  were  probably  based  upon  hallucinations,  for  which  hal- 


151 

lucmations  an  isolated  brain  lesion  was  fourrd,  very  probably  cor- 
rectable with  the  hallucinosis. 

Virtually  all  of  the  11  cases  determined  to  belong  in  the  "un- 
pleasant" group  are  cases  with  severe  renal  disease  as  studied  at 
autopsy. 

Whether  the  unpleasant  emotional  tone  in  these  cases  of  delu- 
sion formation  is  in  any  sense  nephrogenic,  and  whether  particu- 
lar types  of  renal  disease  have  to  do  with  the  unpleasant  emotion, 
must  remain  doubtful.  A  still  more  doubtful  claim  may  be  made 
concerning  the  relation  of  euphoria  to  phthisis.  The  renal  corre- 
lation is  much  more  striking  as  well  as  statistically  better  based. 
A  further  communication  will  attack  the  problem  from  the  side 
of  the  kidneys  in  a  larger  series  of  cases. 

Southard,  E.  E.  Dilatation  of  Cerebral  Ventricles  in  Various 
Functional  Psychoses.  (Abstract.)  Journal  of  Nervous 
and  Mental  Disease,  New  York,  1915,  XLII,  741-743. 

Remarks. 
Case   of  dementia  prrecox,   manic-depressive  insanity  and  in- 
volutional-melancholia  studied  photographically.     The  dilatation 
of  the  ventricles  often  more  marked  in  posterior  parts.     Correla- 
tion of  dilatation  with  excitement. 

Southard,  E.  E.  The  Feeble-minded  as  Subjects  of  Research 
in  Efficiency.1  Proceedings,  National  Conference  Charities 
and  Corrections,  Chicago,  1915,  XLII,  315-319. 

Thom,  D.  A.,  and  Southard,  E.  E.  An  Anatomical  Search  for 
Idiopathic  Epilepsy:  Being  a  First  Note  on  Idiopathic 
Epilepsy  at  Monson  State  Hospital.  Being  Contribution 
from  the  State  Board  of  Insanity  No.  46  (1915.12).  Review 
of  Neurology  and  Psychiatry,  Edinburgh,  1915,  XIII, 
471-486.  Also  (Abstract)  in  Journal  of  Nervous  and. 
Mental  Disease,  1918,  XLVII,  57,  58. 

Summary  and  Conclusions. 
1.  Seventy-six    of   205    brains    of   institutional,    but    otherwise 
unselected,    epileptic   subjects,   i.e.,   37   per   cent,    yielded   brains 
without  substantial  lesions  visible  to  the  naked  eye  upon  super- 
ficial examination  or  dissection. 


Not  published  in  State  Board  of  Insanity  Contribution  (1915.23). 


152 

2.  This  percentage  of  "normal-looking"  brains  is  rather  higher 
than  has  hitherto  been  found  in  institutional,  psychopathic,  now- 
epileptic  subjects,  although  the  dissections  in  the  epileptic  group 
have  probably  not  been  so  extensive  as  in  the  psychopathic  group. 

3.  A  study  has  been  made  of  76  epileptics  with  normal-looking 
brains,  with  the  hope  of  securing  a  number  of  "idiopathic"  cases 
for  special  examination. 

4.  In  order  to  secure  a  group  of  pure  epilepsy,  68  cases  had 
to  be  excluded  as  being  complicated  with  feeble-mindedness, 
acquired  dementia,  or  other  psychotic  symptoms,  leaving  8  ap- 
parently non-psychotic  epileptics  for  study.  Of  these  8,  1  had 
facial  palsy,  1  had  organic-looking  symptoms,  and  2  had  chronic 
leptomeningitis.  Dismissing  the  2  cases  of  chronic  leptomenin- 
gitis we  have  6  cases  from  which  a  truly  idiopathic  brain,  from  a 
histological  point  of  view,  may  be  isolated,  and  it  is  upon  these 
6  brains  that  further  study  must  be  made. 

5.  The  whole  series  affords  an  opportunity  for  general  conclu- 
sions on  certain  classical  questions  of  epileptology,  for  example: — 

Age  at  Onset  {Table  II).  —  (a)  Seventy-two  cases  out  of  a  total 
of  76  with  normal-looking  brains  where  the  age  at  time  of  first 
convulsions  was  known.  Eighteen  {25  per  cent)  began  between 
eleven  and  fifteen  years,  a  period  quite  significant  for  the  disturb- 
ance of  the  nervous  system,  already  predisposed  to  psychochem- 
ical  changes.  Of  the  118  cases  with  abnormal  brains  (with  history 
of  onset  established),  only  9.3  per  cent  had  their  onset  during  this 
same  period,  {b)  The  abnormal  series  show  that  the  percentage 
of  cases  (11  per  cent)  where  the  age  at  onset  was  under  one  year 
was  twice  as  high  (5.5  per  cent)  as  the  normal  series  (suggesting 
birth  injuries  and  congenital  defects).  All  those  cases  where 
the  epilepsy  began  after  the  fortieth  year  were  about  equally 
divided  between  the  normal  and  abnormal  group. 

Duration  of  Epilepsy  {Table  III).  —  The  cases  where  the  dura- 
tion was  of  thirty-five  years  or  more  were  divided  as  follows: 
18.4  per  cent  abnormal  group;  5.3  per  cent  normal  group. 
Those  with  shorter  durations  were  about  equally  divided  between 
the  two  groups. 

Age  at  Death  {Table  IV).  —  Average  age  of  patient  at  time  of 
death,  in  normal  group,  38.9  years;   abnormal  group,  41.44  years. 

Heredity  {Table  V).  — Heredity  present  in  24  per  cent  normal 
cases,  20  per  cent  abnormal  cases,  being  about  equally  divided 
in  either  group  into  the  same  and  allied  types  of  heredity. 

Mental  Status  {Table  VI).  — Only  10  per  cent  of  the  cases  in 


153 

either  group  that  did  not  present  mental  symptoms,  dementia 
being  more  frequent  in  the  normal  group  (46  per  cent),  while 
feeble-mindedness  predominated  in  the  abnormal  group  (53  per 
cent). 

Number  of  Convulsions  {Table  VII).  —  Cases  with  minimum 
number  of  convulsions,  one  or  less  a  month  belonged  largely  to 
abnormal  series,  while  the  cases  where  the  convulsions  occurred  once 
a  day  or  more  frequently  were  usually  found  in  the  normal  series. 

Assigned  Causes  of  Epilepsy  (Table  VIII).  —  The  assigned 
causes  varied  so  widely,  and  in  so  many  instances  were  unknown, 
that  the  data  were  of  little  significance,  excepting  that  head  in- 
juries were  given  as  the  cause  in  9.1  per  cent  in  the  normal  series 
and  in  10  per  cent  in  the  abnormal  series.  Alcohol,  normal 
series,  5.2  per  cent;  abnormal  series,  1  per  cent.  The  causes  of 
death  were  also  so  numerous  that  the  data  are  of  little  impor- 
tance, excepting  that  tuberculosis  was  the  cause  of  death  in  about 
10  per  cent  of  all  cases  in  either  group. 

Alcohol  and  Syphilis  in  Patients  (Table  IX).  —  Alcohol,  12.5 
per  cent  normal  group;  10  per  cent  abnormal  group.  Syphilis, 
1.5  per  cent  normal  group;    2.3  per  cent  abnormal  group. 

We  feel  that,  contrary  to  the  expression  of  the  numerous 
authors  already  quoted,  there  still  remains  some  doubt  that  all 
epilepsies  are  organic  in  nature,  and  it  has  been  the  purpose  of 
this  note  to  introduce  a  more  logical  method  of  anatomical 
search  for  idiopathic  epilepsy  than  has  hitherto  been  applied  to 
the    problem. 

Southard,  E.  E.  Advantages  of  a  Pathological  Classification 
of  Nerve  Cells,  with  Remarks  on  Tissue  Decomplicati on  as 
shown  in  the  Cerebral  and  Cerebellar  Cortex.1  Being  con- 
tribution of  the  Massachusetts  State  Board  of  Insanity 
No.  121  (1915.24).  Transactions,  Association  of  American 
Physicians,  Philadelphia,  1915,  XXX,  531-546.  Also  in 
Bulletin,  Massachusetts  Commission  on  Mental  Diseases, 
Boston,  1918,  II,  75-89. 

Remarks. 

Enough  has  been  said  to  show  that  neuropathological 
research:  — 

1.  Might  do  well  to  engage  on  a  program  of  studying  by 
available  methods  the  differential  viabilities  of  the  various  nerve- 

1  Xot  published  in  State  Board  of  Insanity  Contributions  (1915.24). 


154 

cell  types,  thereby  erecting  an  essentially  "pathological"  classi- 
fication of  nerve  cells  on  the  basis  of  their  powers  of  resistance 
or  survival  values. 

2.  Might  endeavor  to  collect  data  as  to  the  differential  effects 
of  simplification  or  "  decomplication "  of  nerve  tissues,  having  in 
mind  the  evolutionary  or  survival  values  of  the  functions  which 
different  forms  of  decomplication  would  destroy  or  leave  intact. 

1915-16. 

Sotjthakd,  E.  E.,  and  Canavan,  M.  M.  Focal  Lesions  of  the 
Cortex  of  the  Left  Angular  Gyrus  in  Two  Cases  of  Late 
Catatonia.  Being  Scientific  Contribution  of  the  State 
Board  of  Insanity  No.  119  (1915.22).  Read  at  the  seventy- 
first  annual  meeting  of  the  American  Medico-Psychological 
Association,  Old  Point  Comfort,  Va.,  May  11-14,  1915. 
American  Journal  of  Insanity,  Baltimore,  1915-16,  LXXII, 
553-580.  Also  in  Proceedings,  American  Medico-Psycho- 
logical Association,  Baltimore,  1915,  XXII,  227-254. 

Conclusions. 

The  writers  present  two  cases  of  chronic  lesion  of  the  left 
angular  gyrus  which  received  the  clinical  diagnosis  of  dementia 
prsecox.  One  case  showed  a  cyst  of  softening  and  the  other  a 
solitary  tubercle.  It  appears  that  both  lesions  may  well  be  of 
suitable  age  to  correspond  with  the  date  of  onset  of  the  symp- 
toms. Although  not  in  all  respects  typical,  the  diagnosis  of 
dementia  prrecox  seems  to  have  been  accepted  by  the  Boston 
State  Hospital  officers  in  charge  of  the  cases.  Decidedly  atypical 
is  the  age  of  onset  of  the  first  case,  at  forty-one;  the  second  case 
had  its  onset  at  thirty-six. 

The  writers  are  especially  interested  in  the  fact  that  the 
isolated  lesions  in  these  cases  are  in  the  parietal  region,  a  region 
which  has  been  stated  in  previous  work  from  this  laboratory 
to  be  correlated  with  catatonic  symptoms.  Plates  are  presented 
showing  the  site  of  the  lesions. 


155 


1916. 

Southard,  E.  E.  The  causes  of  feeble-mindedness.  Read 
before  the  American  Association  of  Clinical  Criminology,  at 
Buffalo,  October,  1916.  Proceedings,  Annual  Congress, 
American  Prison  Association,  1916,  186-197. 

Southard,  E.  E.  A  Frequency  List  of  Mental  Symptoms  found 
in  17,000  Institutional  Psychopathic  Subjects  (Dan vers  State 
Hospital,  Massachusetts).  (Abstract.)  Journal  of  Nervous 
and  Mental  Disease,  New  York,  1916,  XLIII,  56,  57. 

Southard,  E.  E.  General  Psychopathology.  Psychological 
Bulletin,  Princeton,  N.  J.,  and  Lancaster,  Pa.,  1916,  XIII, 
229-257. 

Southard,  E.  E.  Syphilis  and  the  Psychopathic  Hospital: 
Notes  on  Medical  and  Social  Progress,  especially  in  Neuro- 
syphilis, Boston,  Mass.,  1915.  Being  State  Board  of  In- 
sanity Contribution  No.  131  (1915.34).  Boston  Medical 
and  Surgical  Journal,  1916,  CLXXIV,  50-53  and  81-85. 

Summary. 
The  writer  has  endeavored  in  these  notes  to  present  the  neuro- 
syphilis situation  as  it  faces  us  locally,  and  has  not  endeavored  to 
sum  up  the  neurosyphilis  situation  in  general.  Still  it  is  clear  that 
among  the  ten  papers  of  the  present  series  will  be  found  briefly 
mentioned  most  of  the  aspects  of  the  neurosyphilis  problem  which 
are  appealing  to  the  world  at  the  present  time.  The  humanity  of 
Dr.  Post's  remarks  in  Article  I  needs  no  comment.  Especially 
wise  is  his  note  that  "when  a  social  worker  comes  into  the  family  of 
the  syphilitic,  she  must  dismiss  from  her  mind  any  presupposed 
guilt."  It  is  also  important  to  take  seriously  Dr.  Post's  point 
that  when  all  the  laboratory  signs  of  syphilis  of  the  nervous 
system  are  present,  and  no  clinical  features  of  neurosyphilis  are 
outstanding,  there  must  be  a  serious  question  whether  the  clinical 
work  is  being  done  effectively.  We  need  very  intensive  clinical 
work  in  the  field  of  neurosyphilis  at  the  present  time.  We  cannot 
get  on  with  the  kind  of  loose  work  which  prevails,  it  is  to  be 
feared,  in  certain  fields  of  private  practice  and  in  certain  institu- 
tions. 


156 

The  eagerness  with  which  social  workers  are  beginning  to  take 
up  the  problem  of  the  examination  and  prophylaxis  for  syphilitic 
patients  and  their  families,  and  the  entirely  scientific  manner  of 
the  approach  of  these  social  workers  to  their  problem,  are  to  be 
seen  clearly  in  the  communication  of  Miss  Wright  (Article  II) 
and  of  Miss  Jarrett  (Article  III),  as  well  as  in  the  spirit  of  Dr. 
Gregg's  article  (IV)  on  "Some  Economic  Facts  of  the  Problem." 
How  concrete  the  social  worker's  confrontation  of  the  problem  is 
can  be  seen  from  the  appendices  to  Miss  Wright's  article  (Article 
II),  embodying  the  blank  forms  which  are  used  in  the  syphilis 
family  investigation.  The  syphilis  of  railroad  men  and  even  of 
a  lighthouse  man,  of  caterers,  cooks  and  nursemaids,  mentioned 
by  Dr.  Gregg,  is  a  mention  of  nothing  new  to  the  community; 
yet  we  cannot  be  too  insistent  upon  the  familiarity  of  such  in- 
formation. These  facts  should  stand  out  prominently  in  our 
propaganda. 

Article  V,  by  Beasley  and  H.  M.  Anderson,  upon  the  mental 
features  of  the  congenital  cases,  is  a  mere  beginning  of  work  in 
this  direction.  How  much  of  our  truancy  and  juvenile  court 
problem  is  due  to  congenital  syphilis  cannot  yet  be  safely  esti- 
mated, but  whatever  the  true  percentage  of  the  luetic  fraction 
among  these  antisocial  cases,  the  absolute  numbers  are  sizable 
enough  to  warrant  attention.  The  impairment  of  the  sense 
organs  and  the  elementary  psychic  apparatus,  brought  out  in  this 
article  as  characteristic  of  congenital  syphilitics,  is  of  some  gen- 
eral importance. 

There  follow  articles  (VI,  VII,  VIII  and  IX)  upon  the  diag- 
nostic situation  in  neurosyphilis.  Article  VI,  by  Solomon  and  his 
associates,  is  a  continuation  of  his  previous  work,  and  not  only 
emphasizes  the  fact  that  the  gold  sol  examination  is  essential  in 
cerebrospinal  fluid  examinations,  but  also  that  it  is  at  present 
impossible  to  tell  the  paretic  from  the  non-paretic  form  of  neuro- 
syphilis. Upon  this  fact  is  based  the  important  conclusion  above 
mentioned  in  the  ninth  section  of  these  notes. 

Article  VII  shows  that  the  cell  count  in  the  cerebrospinal  fluid 
is  not  an  index  to  the  quality  or  degree  of  irritative  and  paralytic 
changes  shown  in  the  symptoms  of  cases  of  neurosyphilis. 

Article  VIII  brings  up  a  rather  large  question,  —  whether  the 
laboratory  signs  of  neurosyphilis,  and,  in  particular,  signs  of  ex- 
tensive chronic  inflammation  of  the  nerve  system,  appear  before 
the  occurrence  of  any  characteristic  mental  symptoms.  We  have 
been  fortunate  to  discover  a  certain  number  of  these  cases  which, 


157 

of  course,  will  often  elude  observation  because,  having  no  mental 
symptoms  or  other  symptoms  of  importance,  such  cases  would 
not  naturally  be  subject  to  intensive  examination.  An  extension 
of  family  work  in  syphilis,  and  especially  neurosyphilis,  may  un- 
cover a  great  many  more  of  these  cases  that  we  have  termed 
"latent"  neurosyphilis,  or  somewhat  fantastically,  general  paresis 
sine  paresi.  Do  these  findings  indicate  certain  unsuspected  con- 
ditions in  the  genesis  of  neurosyphilis?  It  is  too  early  to  make 
such  a  claim.  It  is  certain  that,  after  all,  such  cases  deserve 
immediate  and  intensive  treatment. 

Article  IX  makes  a  special  point  concerning  the  gold  sol 
reaction,  namely,  the  point  that  the  cerebrospinal  syphilitic  gold 
sol  reaction  is  in  some  sense  a  forme  fruste  of  the  characteristic 
paretic  reaction.  Should  this  point  be  maintained,  the  essential 
unity  of  the  two  conditions  would  be  still  further  established. 
The  true  explanation  of  the  forme  fruste  here  described  must 
probably  await  developments  in  colloidal  chemistry. 

Article  X,  of  which  the  present  paragraph  forms  a  part,  en- 
deavors to  give  a  brief  account  of  the  special  aspects  of  the 
neurosyphilis  situation  which  have  attracted  attention  at  the 
Psychopathic  Hospital. 

Southard,  E.  E.,  and  Solomon,  H.  C.  Latent  Neurosyphilis 
and  the  Question  of  General  Paresis,  Sine  Paresi.  Being 
State  Board  of  Insanity  Contribution  No.  129  (1915.32). 
The  general  conclusions  of  this  paper  were  read  by  Dr. 
Solomon  at  the  April  meeting  of  the  Boston  Society  of 
Psychiatry  and  Neurology.  Boston  Medical  and  Surgical 
Journal,  1916,  CLXXIV,  8-15. 

Summary. 

1.  There  is  a  group  of  cases  showing  the  laboratory  signs 
characteristic  of  central  nervous  system  syphilis:  (a)  positive 
Wassermann  reaction  in  the  serum,  (6)  positive  Wassermann 
reaction  in  the  spinal  fluid,  (c)  pleocytosis,  (d)  excess  of  globulin 
and  (e)  of  albumin  in  the  spinal  fluid,  (/)  gold  sol  reaction  of 
central  nervous  system  syphilis,  and  which  show  no  sign  or  symp- 
tom of  neural  syphilis. 

2.  We  believe  these  cases  represent  a  form  of  chronic  cerebro- 
spinal syphilis,  probably  paretic  in  type. 

3.  They  have  the  greatest  theoretical  and  practical  significance 
in  the  consideration  of  the  life  history  of  neural  syphilis,  in  the 


158 

concept  of  allergie,  in  regard  to  results  of  treatment,  and  finally 
as  to  the  evaluation  of  the  laboratory  tests. 

4.  Here  is  perhaps  offered  the  last  link  to  form  a  complete 
chain  between  the  symptoms  of  the  primary  stage  of  syphilis  and 
its  final  termination  of  life  as  the  result  of  the  diseases  cerebro- 
spinal syphilis  or  general  paresis. 

Southard,  E.  E.  The  Major  Divisions  of  Mental  Hygiene  — 
Public,  Social,  Individual.  Massachusetts  Society  for 
Mental  Hygiene  Publication  No.  18,  from  the  Boston 
Medical  and  Surgical  Journal,  1916,  CLXXV,  404-406. 

Southard,  E.  E.  Social  Research  in  Public  Institutions.1 
Proceedings,  National  Conference,  Charities  and  Correc- 
tions, Chicago,  1916,  376-386. 

Southard,  E.  E.  Psychopathic  Delinquents.2  Proceedings, 
National  Conference,  Charities  and  Corrections,  Chicago, 
1916,  529-538. 

Southard,  E.  E.  The  Psychopathic  Hospital's  Function  of 
Early  Intensive  Service  for  Persons  not  Legally  Insane.3 
Being  Contribution  No.  154  (1916.12)  "The  Psychopathic 
Hospital's  Function  of  Early  Intensive  Service  for  Persons 
not  Legally  Insane,"  in  Proceedings  of  the  National  Con- 
ference of  Charities  and  Corrections,  1916.  Published  in 
the  Journal  of  Educational  Psychology,  December,  1916, 
Vol.  VII.  (Abstract.)  Proceedings,  National  Conference, 
Charities  and  Corrections,  Chicago,  1916,  277-279. 

Southard,  E.  E.  Dissociation  of  Parenchymatous  (Neuronic) 
and  Interstitial  (Neuroglia)  Changes  in  the  Brains  of  Certain 
Psychopathic  Subjects,  especially  in  Dementia  Prsecox. 
Being  M.  C.  M.  D.  Contribution  No.  164  (1916.22). 
Transactions,  Association  of  American  Physicians,  Phila- 
delphia, 1916,  XXXI,  293-310.  Also  in  Bulletin  of  Massa- 
chusetts Commission  on  Mental  Diseases,  Boston,  1917,  I, 
236-253. 

1  Not  published  in  Bulletin  of  Massachusetts  Commission  on  Mental  Diseases.     (1916.10). 

2  Not  published  in  Bulletin  of  Massachusetts  Commission  on  Mental  Diseases.     (1916.11). 

3  Not  published  in  Bulletin  of  Massachusetts  Commission  on  Mental  Diseases.     (1916.12). 


159 


Summary. 
To  sum  up:  — 

1.  Parenchymatous  (neuronic)  lesions  and  interstitial  (neurog- 
lia) lesions  may  be  dissociated  and  combined,  much  as  similar 
lesions  in  the  kidney. 

2.  A  case  of  manic-depressive  psychosis  failed  to  show  con- 
vincing degrees  of  parenchymatous  lesions. 

3.  Dementia  preecox  cases  had  marked  parenchymatous  dis- 
order, to  which  gliosis  was  not  at  all  proportionate. 

4.  It  is  necessary  to  find  and  study  by  like  methods  a  good 
group  of  non-tuberculous  cases  of  dementia  prsecox,  so  as  to 
exclude  tuberculosis  from  having  a  share  in  the  production  of 
these  lesions. 

Southard,  E.  E.  The  Comparative  Convolutional  Complexity 
of  Male  and  Female  Brains.  (Abstract.)  Science,  Lan- 
caster, Pa.,  1916.     (New  series,  Vol.  XLIII,  900.) 

Remarks. 
The  material  for  the  study  consists  of  brain  photographs  (six 
views  of  each  brain)  in  the  collection  of  the  Massachusetts  State 
Board  of  Insanity,  derived  from  over  500  brains  in  the  possession 
of  various  State  and  private  institutions  of  Massachusetts,  in- 
cluding so-called  "normal"  brains  and  brains  from  a  variety  of 
psychopathic  subjects.  The  method  of  the  study  is  numerical, 
based  upon  counts  of  fissures  and  fissurets.  The  results,  so  far 
as  interpretable,  show  no  great  sex  difference  in  degree  of 
fissuration. 

Southard,  E.  E.  On  the  Application  of  Grammatical  Categories 
to  the  Analysis  of  Delusions.  The  Philosophical  Review, 
1916,  XXV,  424-455.  Also  in  Bulletin  of  Massachusetts 
Commission  on  Mental  Diseases,  Boston,  1917,  I,  22-50. 

Remarks. 
The  object  of  this  paper  has  been  to  illustrate  the  method  of 
Royce's  logical  seminary  at  Harvard.  No  attempt  has  been 
made  to  describe  the  method,  which  is  comparative  rather  than 
observational  or  statistical.  When  the  logician  superposes  the 
categories  of  Science  A  upon  the  material  of  Science  B,  or  com- 
pares the  categories  of  both,  he  is  not  at  all  sure  of  important 


160 

results.  If  he  obtains  too  extensive  or  too  numerous  identities 
by  means  of  his  comparisons,  he  may  be  compelled  to  decide  that 
identity  of  categories  means  actual  unity  of  materials.  Thus,  in 
the  present  instance,  the  reader  may  be  the  more  ready  to 
swallow  the  identity  of  certain  categories  in  grammar  and  psycho- 
pathology,  simply  because  he  fundamentally  believes  in  a  larger 
degree  of  identity  of  speech  and  thought.  In  the  event  of  such 
a  nominalistic  view  as  that,  the  only  merit  of  the  present  essay 
would  consist  in  spreading  a  sound  method  over  new  materials 
of  the  same  sort;  the  method  would  not  then  be  comparative  in  a 
very  rich  sense  of  the  term.  But,  even  if  speech  and  thought 
are  as  closely  allied  as,  e.g.,  Max  Miiller  thought  them  to  be, 
the  fact  still  remains  that  the  categories  of  linguistics  and  of 
psychology  have  not  been  wrought  into  their  present  form  by  the 
same  group  of  men  or  under  the  same  group  of  interests.  If  there 
is  a  partial  identity  of  scientific  materials,  there  is  no  evidence  of 
identity  of  categories.  The  comparative  method  will  then  obtain  a 
certain  scope,  even  if  that  scope  is  limited  to  trying-out  of  special 
methods  devised  by  linguists  inexpert  in  technical  psychology. 

I  hesitate  to  set  forth  the  point;  but  I  am  left  with  a  queer 
impression  that  linguistics  falls  short  of  representing  logic  in 
somewhat  the  same  way  that  psychopathology  falls  short  of  repre- 
senting psychology.  I  do  not  so  much  refer  to  the  prevalence 
of  concepts  like  "phonetic  decay,"  "empty  words,"  "anomalism," 
etc.,  in  linguistics,  although  these  concepts  certainly  suggest 
human  frailty  quite  outside  the  frame  of  classical  logic.  I  do  not 
wish  to  construct  a  false  epigram  to  the  effect  that  linguistics  is  a 
kind  of  pathology  of  logic,  attractive  as  this  epigram  might  be. 
My  point  is  that  human  facts  are  got  at  more  readily  in  linguis- 
tics and  in  psychopathology  than  in  logic  and  in  so-called  normal 
psychology. 

For  example,  if  I  try  to  determine  the  logical  modality  of 
something  and  to  affix  the  proper  epithet  (necessary,  impossible, 
contingent,  possible),  I  sink  into  a  morass  of  factual  doubts. 
But,  equipped  with  the  fundamental  grammatical  moods  (im- 
perative, indicative,  subjunctive,  optative),  I  can  dismiss  my 
doubts  by  describing  them  under  one  of  these  mood  aspects, 
regardless  of  objective  reality,  truth  to  me,  truth  to  Mrs.  Grundy, 
or  any  situation  except  that  depicted  by  the  statement  in  ques- 
tion. The  grammatical  moods  deal  with  evidence  unweighed; 
the  logical  modalities  require  more  weighing  of  evidence  than  is 
as   a  rule  humanly   possible.     Psychopathology   also   deals   with 


161 

evidence  unweighed.  Particularly  is  this  true  of  that  portion 
of  psychopathology  which  deals  with  false  beliefs.  Granted 
that  some  beliefs  are  prima  facie  fantastic  and  to  us  incredible. 
By  the  patient  these  fantastic  and  incredible  beliefs  are  believed, 
but  the  nature  and  history  of  these  fantastic  beliefs  may  well  be 
investigated  to  learn  whether  we  are  not  dealing  with  a  so-called 
wish-fulfilment  (a  Freudian  technical  term)  or  with  a  kind  of 
degradation  of  what  the  linguist  might  term  an  optative  attitude. 
But  the  majority  of  false  beliefs  are  not  prima  facie  fantastic  and 
incredible.  They,  on  the  contrary,  require  the  test  of  experience. 
They  represent  pragmatic  situations.  Granting  the  truth  of 
certain  hypotheses,  we  say,  these  beliefs  might  be  accepted  also 
as  truth.  Our  thesis  is  that  these  pragmatic  delusions  do  not 
represent  a  conceived  wish-fulfilment,  if  by  wish  is  meant  a 
fancied  situation.  On  the  other  hand,  these  pragmatic  delusions 
appear  to  hang  rather  upon  the  degradation  of  a  subjunctive 
attitude,  that  is,  upon  taking  as  true  a  certain  hypothesis.  But 
neither  fantastic  nor  pragmatic  delusions  can  readily  be  classed 
under  the  logical  modalities,  e.g.,  as  possible  or  contingent, 
however  possible  and  contingent  they  actually  seem  to  the 
patient.  In  any  event,  they  are  or  will  shortly  turn  out  to  be 
impossible,  logically  speaking,  and  if  the  patient  were  to  ascribe 
*  any  logical  modality  thereto  he  would  be  likely  to  deal  in  neces- 
sities on  the  one  hand  and  impossibilities  on  the  other.  Gram- 
matically speaking,  the  degraded  optative  belief  may  even  set 
into  an  imperative,  and  beliefs  degraded  from  both  the  optative 
and  the  subjunctive  appeal  to  the  patient  as  indicative,  if  not 
yet   imperative. 

From  our  superficial  study  of  the  categories  of  grammar  as 
they  revolve  about  the  verbs,  we  have  come  upon  two  consider- 
ations of  value  that  are  not  entirely  obvious,  the  psychopathic 
analogue  of  the  grammatical  "voice,"  and  the  question  of  two 
main  types  of  delusion  degraded,  respectively,  from  "subjunc- 
tive" and  "optative"  attitudes. 

I  believe  that  the  "voice"  distinction  will  forthwith  appeal  to 
all  psychiatrists  as  valid  within  its  range.  The  distinction  seeks 
to  express  the  relation  between  the  world  and  the  individual  from 
the  individual's  point  of  view  under  two  forms,  (a)  that  in  which 
the  self  is  active,  and  (6)  that  in  which  the  self  is  passive  in  rela- 
tion to  the  environment;  but  in  the  third  place  (c)  the  relation  of 
the  individual  to  himself  is  suggested,  viz.,  under  the  "middle" 
or  reflexive  relation.     Whether  the  reflexive  relations  of  the  self 


162 

break  up  further  into  a  group  where  the  "I"  dominates  the 
"me"  and  another  where  the  "me"  overpowers  the  "I"  (that 
is,  whether  the  ego  is  sometimes  active  in  respect  to  itself  and 
sometimes  passive),  is  a  question  partly  of  fact,  but  more  of  the 
nature  of  the  self  and  of  the  whole  difficult  topic  of  self-activity. 

Whether  the  distinction  between  pragmatic  delusions  (as 
it  were,  precipitated  subjunctives)  and  fantastic  delusions  (as 
it  were,  precipitated  optatives)  is  valid  must  remain  undeter- 
mined. The  distinction  has  at  least  the  value  of  suggesting  a 
similar  distinction  in  human  character  in  general;  both  distinc- 
tions may  be  derived  from  identical  psychological  facts. 

If  in  the  practical  handling  of  a  patient,  or  indeed  of  any  one 
else  in  a  situation  hard  to  interpret,  the  observer  can  make  out 
the  "voice"  of  the  subject's  situation  from  the  subject's  point  of 
view,  and  can  secondly  determine  whether  the  difficulty  rests 
upon  trouble  with  hypotheses  or  trouble  with  wishes,  much  is 
gained  surely. 

We  saw  also  from  our  incidental  study  of  person,  number,  and 
gender  how  important  might  become  the  question  of  monadic, 
diadic,  triadic,  or  polyadic  situations  involving  false  beliefs. 
The  collection  of  groups  of  such  situations  for  analysis  is  certainly 
indicated,  naturally  with  invariable  reference  to  the  "voice," 
active  or  passive,  of  the  patient  or  central  figure.  Fiction  and 
drama  could  throw  some  light  on  these  matters. 

In  the  gathering  of  data  for  analysis,  it  is  clear  also  that  the 
time-relations  must  also  be  studied  from  the  patient's  point  of 
view,  to  the  end  of  determining  whether  the  particular  subjunc- 
tive precipitate  has  relation  to  some  central  point  in  the  past, 
whether  the  particular  optative  precipitate  has  relation  to  a 
present  or  present  perfect  situation,  or  whether  other  "tenses" 
come  in  question. 

Southard,  E.  E.  The  Comparison  of  the  Mental  Symptoms 
found  in  Cases  of  General  Paresis  with  and  without  Coarse 
Brain  Atrophy.  Being  Contribution  of  the  State  Board  of 
Insanity  No.  38  (1915.4).  Journal  of  Nervous  and  Mental 
Disease,  1916,  XLIII,  204-216. 

Summary  and  Conclusions. 
The  possession  of  a  suitable  statistical  background  (the  Dan- 
vers  Case  Symptom  Index)  has  rendered  worth  while  an  orient- 
ing study  in  the  mental  symptomatology  of  general  paresis.     A 


163 

group  of  38  general  paretics  whose  brains  were  specially  exam- 
ined and  described  by  the  writer  has  been  divided  into  two 
groups  according  to  whether  there  was  or  was  not  coarse  evi- 
dence of  brain  atrophy.  The  cases  without  brain  atrophy  were 
termed  "mild"  and  those  with  brain  atrophy  were  termed 
"severe,"  although  these  designations  are  only  approximations 
to  accuracy;  the  groups  are,  however,  in  no  sense  "early"  and 
"prolonged." 

Symptomatically  the  two  groups  show  several  surprising  con- 
cordances and  a  number  of  instructive  divergencies.  Thus  am- 
nesia, motor  restlessness,  disorientation,  dementia  and  depression 
lead  both  series  and  in  that  order  (except  that  allopsychic  delu- 
sions stand  fourth  in  the  "mild"  series  and  are  far  less  common 
in  the  "severe").  Are  amnesia  and  dementia,  therefore,  in  no 
sense  proportional  to  brain  tissue  loss  f 

Nineteen  symptoms  occurred  in  20  per  cent  or  over  of  the 
paretic  series,  viz.,  the  five  just  mentioned,  and  nine  others  (irri- 
tability, defective  judgment,  psychomotor  excitement,  autopsychic 
delusions,  insomnia,  aphasia,  hallucinations  of  doubtful  or  un- 
specified nature,  convulsions,  visual  hallucinations)  not  always 
in  like  proportion  in  the  two  series.  Five  other  symptoms  oc- 
curred in  each  series,  but  symptoms  quite  sundered  from  one 
another  in   general   significance. 

The  "mild"  cases  showed  a  group  of  symptoms  which  might 
be  termed  contra-environmental,  viz.,  allopsychic  delusions,  sic- 
chasia    (refusal    of    food),    resistiveness,    violence,    destructiveness. 

The  "severe"  cases  showed  a  group  of  symptoms  of  a  quite 
different  order,  affecting  personality,  either  to  a  ruin  of  its  mech- 
anisms in  confusion  and  incoherence,  or  to  the  mental  quietus 
involved  in  euphoria,  exaltation  or  expansiveness. 

Some  speculations  are  offered  in  the  text  as  to  the  perversion 
of  inhibition  or  inco-ordination  of  inhibition  which  the  largely  ir- 
ritative lesions  of  the  "mild"  cases  are  presumably  effecting  in 
the  perhaps  more  seriously  affected  frontal  areas.  When  these 
are  still  more  gravely  affected,  as  to  the  point  of  atrophy,  then 
the  intrapsychic  disorder  might  well  become  more  manifest,  e.g., 
in  the  distinctive  symptoms  of  the  "severe"  group  just  men- 
tioned. 

In  a  series  of  17,000  clinical  cases  (of  all  sorts  of  mental  disease, 
alive  and  dead,  recovered  and  impaired)  symptomatologically 
analyzed,  there  were  but  ten  symptoms  occurring  in  20  per  cent 
or  over;    these  were,  in  order,  psychomotor  excitement,  allopsychic 


164 

delusions,  dementia,  auditory  hallucinations,  motor  restlessness, 
depression,  autopsychic  delusions,  insomnia,  incoherence,  amnesia. 
Each  of  these  is  represented  high  in  general  paresis  (i.e.,  in  20 
per  cent  or  over),  except  that  auditory  hallucinations  are  in- 
frequent in  both  "mild"  and  "severe"  cases,  and  allopsychic 
delusions  are  infrequent  in  "severe"  cases.  There  may  be  topo- 
graphical reasons  for  the  paucity  of  auditory  hallucinations  in 
general  paresis.  The  method  of  production  of  allopsychic  delu- 
sions in  general  paresis  should  be  studied,  since  there  can  be  no 
such  alliance  of  allopsychic  delusions  and  auditory  hallucinations 
therein  as  is  perhaps  the  rule  in  dementia  praecox. 

If  we  consider  the  next  nine  symptoms  in  order  in  17,000  cases 
of  mental  disease  at  large,  viz.,  violence,  visual  hallucinations, 
irritability,  defective  judgment,  disorientation,  destructiveness,  con- 
fusion, resistiveness  and  somatic  delusions,  we  find  only  the  last, 
viz.,  somatic  delusions,  not  represented  in  either  group  in  fair 
proportion,  although  (as  above  stated)  confusion  is  poorly  rep- 
resented in  the  "mild"  cases  and  violence,  destructiveness  and 
resistiveness  are  poorly  represented  in  the  "severe"  cases. 

Aphasia,  hallucinations  of  doubtful  or  unspecified  nature  and 
convulsions  appear  to  be  frequent  symptoms  in  general  paresis 
that  do  not  figure  at  all  so  largely  in  mental  disease  as  a  whole. 
Besides  these,  sicchasia  of  the  "mild"  group,  and  euphoria,  exal- 
tation and  expansiveness  of  the  "severe"  group,  appears  to  stand 
out  for  general  paresis  against  mental  disease  as  a  whole. 

The  most  positive  results  of  this  orienting  study  appear  to  be 
the  unlikelihood  of  euphoria  and  allied  symptoms  in  the  "mild" 
or  non-atrophic  cases,  and  the  unlikelihood  of  certain  symptoms, 
here  termed  contra-environmental,  in  the  "severe"  or  atrophic 
cases.  Perhaps  these  statistical  facts  may  lay  a  foundation  for 
a  study  of  the  pathogenesis  of  these  symptoms.  Meantime  the 
pathogenesis  of  such  symptoms  as  amnesia  and  dementia  cannot 
be  said  to  be  nearer  a  structural  resolution,  as  these  symptoms 
appear  to  be  approximately  as  common  in  the  "mild"  as  in  the 
"severe"  groups. 


165 


1917. 

Southard,  E.  E.,  and  Canavan,  M.  M.  Autopsy  Material  of 
Poliomyelitis  Epidemic  of  1916.  (Abstract.)  Journal  of 
Nervous  and  Mental  Disease,  1917,  XL VI,  217,  218. 

Southard,  E.  E.  On  Descriptive  Analysis  of  Manifest  De- 
lusions from  the  Subject's  Point  of  View.  Being 
M.  C.  M.  D.  Contribution  No.  150  (1916.8).  Journal  of 
Abnormal  Psychology,  Boston,  1916-17,  XI,  189-202.  Also 
in  Bulletin  of  Massachusetts  Commission  on  Mental  Dis- 
eases, Boston,  1917,  I,  80-91. 

Summary. 
The  writer  aims  at  a  descriptive  analysis  of  manifest  delusions 
and  false  beliefs  taken  subjectively,  i.e.,  from  the  patient's  point 
of  view.  He  regards  this  as  an  indispensable  preliminary  to  ex- 
planatory synthesis  of  psychopathic  situations,  even  should  it 
turn  out  that  aliquid  latens  is  the  nucleus  of  such  situations. 
Practically  he  proposes  a  minimum  of  terms  which  the  tyro  in 
psychiatric  examination  must  aim  to  get  from  a  lucid  patient 
entertaining  or  alleged  to  entertain  false  beliefs.  In  addition  to 
(a)  the  person  or  persons  involved,  (6)  the  number  of  persons 
involved,  (c)  the  sex  of  these  persons,  (d)  the  time,  past,  present 
or  future,  in  which  the  noxious  event  or  condition  is  believed  to 
occur,  the  writer  deals  also  with  (e)  the  "voice"  in  which  the 
patient  takes  himself  to  be.  The  patient  from  his  own  point  of 
view  regards  himself  as  at  odds  with  the  environment 

(1)  as  it  were  actively 
(PATIENT  >  ENVIRONMENT) 

or  (2)  as  it  were  passively 

(PATIENT < ENVIRONMENT),  or  again  as  at  odds  with  himself, 
either 

(3)  with  higher  (spiritual)  self  dominant 
(EGO>"ME") 

or  (4)  with  lower  (material)  self  dominant 
(EGO<"ME"). 


166 

The  writer  deals  also  with  (/)  the  distinction  of  "mood,"  find- 
ing that  patients  above  the  "imperative"  level  entertain  either 
irrational  delusions  or  fantastic  ones.  The  writer  speculates  that 
irrational  (pragmatic)  delusions  represent  hypotheses  taken  as 
facts  (i.e.,  "subjunctives"  degenerating  into  "indicatives"),  and 
that  fantastic  (prima  facie  false)  beliefs  represent  wishes  taken 
as  facts  (i.e.,  "optatives"  degenerating  into  "indicatives"). 
Possibly  those  who  transcend  the  imperative  and  indicative  levels 
in  normal  development  split  into  two  classes  of  persons,  those 
with  a  leaning  toward  hypotheses  (highest  development,  men  of 
science)  and  those  with  a  leaning  toward  wishes  (highest  devel- 
opment, artists).  In  the  body  of  the  paper  some  account  is 
given  of  the  comparative  method  by  which  these  items  of  psy- 
chiatric analysis  were  obtained,  a  fuller  account  of  which  has 
appeared  in  the  "Philosophical  Review"  in  a  paper  written  in 
honor  of  Prof.  Josiah  Royce. 

Southard,  E.  E.  General  Psychopathology.  Psychological 
Bulletin,  Princeton,  N.  J.,  and  Lancaster,  Pa.,  1917,  XIV, 
193-215. 

Southard,  E.  E.  The  Correlation  of  Brain  Anatomy,  Mental 
Tests  and  School  or  Hospital  Records  in  a  Series  of  Feeble- 
minded Subjects  (Waverley  Anatomical  Research  Series). 
(Abstract.)  Journal  of  Nervous  and  Mental  Disease, 
Lancaster,  Pa.,  1914,  XLIII,  454-457. 

Remarks. 
Dr.  Southard  presented  an  account  of  the  first  instalment  of 
work  on  the  brains  of  the  feeble-minded  done  under  the  auspices 
of  the  Waverley  School  for  Feeble-minded.  He  called  attention 
to  the  extraordinarily  small  amount  of  work  which  has  been  done 
upon  the  anatomy  of  brains  of  feeble-mindedness,  speaking  of 
the  work  of  Bourneville,  Hammarberg  and  the  early  work  of 
Wilmarth  in  this  country.  He  spoke  of  the  present  as  an  aus- 
picious period  for  work  in  this  field  on  account  of  the  great 
achievements  in  cortex  topography  of  recent  years.  He  described 
the  systematic  photography  of  the  brains  from  above,  below, 
from  the  two  sides  and  from  the  two  mesial  aspects,  and  of  the 
further  photography  of  frontal  sections.  Thereupon  microscopic 
work  could  be  done  with  the  full  advantage  of  correlations  with 


167 

the  gross  appearances,  such  as  anomalies,  atrophies  and  other 
focal  lesions. 

Another  reason  for  working  eagerly  at  this  topic  at  this  time 
was  the  fact  that  mental  tests  are  now  available,  so  that  we  can 
compare:  (a)  the  psychometric  level  of  the  patient,  (6)  the 
functional  level  of  the  patient  as  exhibited  clinically  and  educa- 
tionally, and  (c)  the  level  of  brain  development. 

The  speaker  insisted  upon  the  importance  of  studying  effi- 
ciency in  the  material  of  feeble-mindedness.  He  considered  that 
feeble-mindedness  forms  the  best  material  now  available  for  re- 
search in  efficiency,  and  called  attention  to  the  fact  that  all  the 
modern  books  upon  efficiency  had  neglected  the  field.  Just  as 
the  Montessori  method  was  a  logical  descendant  of  the  work  of 
Seguin,  so  new  ideas  in  the  education  of  the  normal  derive  from 
the  more  modern  work  in  the  education  of  the  feeble-minded. 

If  correlations  between  the  psychometric  and  practical  capacity 
levels  of  the  patients  on  the  one  hand,  and  the  trained  brains  on 
the  other,  can  be  made,  then  possibly  something  new  concerning 
the  nature  of  work  in  this  connection,  and  comparison  between 
appearances  in  the  parietal  lobes  and  those  in  the  frontal  lobes, 
would  obviously  be  of  importance. 

Southard,  E.  E.,  and  Canavan,  M.  M.  The  Stratigraphical 
Analysis  of  Finer  Cortex  Changes  in  Certain  Normal- 
looking  Brains  in  Dementia  Prsecox.  Being  M.  C.  M.  D. 
Contribution  No.  166  (1916.24).  Journal  of  Nervous  and 
Mental  Disease,  New  York,  1917,  XLV,  97-129.  Also  in 
Bulletin  of  Massachusetts  Commission  on  Mental  Diseases, 
Boston,  1917,  I,  261-293. 

Summary  and  Conclusions. 

The  writers  present  an  analysis,  chiefly  stratigraphical,  of 
certain  lesions,  notably  nerve  cell  loss  and  gliosis  (including 
satellitosis)  in  four  cases  of  dementia  prsecox.  These  cases  were 
cases  which  showed  no  gross  aplasia,  sclerosis  or  atrophy  in  the 
gross  and  yet  exhibited  symptoms  of  two  years'  or  greater  dura- 
tion, entitling  them  to  be  considered  in  the  dementia  prsecox 
group. 

In  connection  with  this  work,  a  review  of  Kraepelin's  estimate 
of  structural  work  in  dementia  prsecox  brains  is  offered,  and  the 


168 

stratigraphical  data  are  presented  in  relation  to  Kraepelin's  views 
as  to  the  functions  of  suprastellate  and  infrastellate  layers. 

Absence  of  suprastellate  lesions  in  a  case  of  the  paranoic  or 
paraphrenic  group  was  noted,  but  there  was  no  special  evidence 
of  schizophrenia  in  this  case  as  clinically  viewed;  the  case  did 
show  infrastellate  lesions  in  areas  contiguous  with  one  another 
in  the  two  flanks  of  the  brain.  It  might  be  possible  to  correlate 
the  late  catatonia  and  late  hallucinosis  in  the  case  with  these 
infrastellate  lesions.  Other  cases  possibly  more  typical  of 
dementia  prsecox  exhibited  lesions  both  in  the  suprastellate  and 
infrastellate  regions,  sometimes  numerous,  sometimes  isolated 
and  apparently  capricious  in  distribution.  No  good  example  of 
lesions  chiefly  limited  to  the  suprastellate  layers  has  been  found. 

Gliosis  and  satellitosis  do  not  follow  the  nerve  cell  losses.  The 
same  holds  true  of  shrinkage  changes  and  axonal  reactions.  Nor 
is  satellitosis  closely  associated  either  with  shrinkage  changes 
(which  are  not  numerous  in  this  series)  or  with  axonal  reactions. 
The  dissociation  of  parenchymatous  (neuronic)  and  interstitial 
(neuroglia)  changes  reported  in  a  previous  communication  is 
further  emphasized. 

Southard,  E.  E.  The  Effects  of  High  Explosives  upon  the 
Central  Nervous  System:  A  Review  of  Mott's  Lettsomian 
Lectures,  1916,  and  G.  Elliot  Smith's  "Shell  Shock  and  its 
Lessons."  Mental  Hygiene,  Concord,  N.  H.,  1917,  I, 
397-405. 

Southard,  E.  E.  Proposals  for  a  Sequence  of  Disease  Groups 
to  be  successively  considered  in  the  Practical  Diagnosis  of 
Mental  Diseases.  (Abstract.)  Journal  of  Nervous  and 
Mental  Disease,  New  York,  1917,  XLVI,  277-279. 

Remarks. 
The  proposals  look  to  a  practical  rather  than  a  theoretical 
ordering  of  mental  disease  groups.  The  classification  is  "arti- 
ficial" rather  than  "natural,"  as  John  Stuart  Mill  used  those 
terms.  The  familiar  issues  of  etiology  and  entifiability  are  not 
here  raised.  Instead,  the  jundamentum  divisionis  is  the  practical 
("artificial")  one  of  separation  along  lines  of  available  tests  in 
the  interest  of  differentiated  treatment  or  counsel;  e.g.,  the 
syphilitic  group  stands  first,  neither  in  virtue  of  frequency  nor 
of  theoretical  simplicity,  but  because  of  the  complement-fixation 


169 

test,  and  the  therapeutic  possibilities  in  the  syphilitic  group. 
But  the  method  is  not  necessarily  one  of  successive  elimination 
of  disease  groups  until  the  correct  group  is  reached.  In  the 
majority  of  cases  the  entire  gamut  of  a  dozen  or  more  groups 
must  be  applied.  For  a  given  case  may  be  one,  e.g.,  of  a  syphi- 
litic, feeble-minded,  epileptic,  alcoholic,  senile  with  coarse  brain 
disease.  A  provisional  sequence  is  composed  of  the  syphilitic, 
feeble-minded,  epileptic,  alcoholic,  encephalopathic,  somatopathic, 
senescent,  schizophrenic,  cyclothymic,  psychoneurotic,  psycho- 
pathic, special,  dubious  and  simulant  groups,  and  the  non- 
psychotic. 

Southard,  E.  E.  On  the  Focality  of  Microscopic  Brain  Lesions 
found  in  Dementia  Prsecox.  Being  M.  C.  M.  D.  Con- 
tribution No.  201  (1917.21).  Archives  of  Neurologie  and 
Psychiatrie,  1919,  I,  172-192.  Also  in  Transactions,  Asso- 
ciation of  American  Physicians,  Philadelphia,  1917,  XXXII, 
435-459,  and  Bulletin  of  Massachusetts  Commission  on 
Mental  Diseases,  Boston,  1918-19,  II,  45-67. 

Summary. 

Thanks  to  the  work  of  Elliot  Smith,  Bolton,  Campbell,  Brod- 
mann,  Ramon  y  Cajal  and  others,  the  neuropathologist  can  now 
afford  to  attempt  finer  functional  histologic  correlations  in  the 
field  of  mental  diseases,  thus  aiding  in  the  problems  of  micro- 
localization.  The  antilocalizing  tendencies  of  the  Wundtians 
and  the  interest  in  merely  logical  categories  taken  by  Freudians 
should  not  interfere  with  progress  in  microlocalization.  Dementia 
prsecox,  for  example,  can  be  called  a  matter  of  maladaptation 
of  the  patient  to  his  environment  or  of  the  patient  to  himself, 
and  also  a  disease  characterized  by  cortical  changes. 

Previous  work  had  shown  anomalies  in  a  high  proportion  of 
dementia  prsecox  brains,  and  in  a  correspondingly  low  proportion 
of  the  brains  of  manic-depressive  subjects.  These  anomalies  may 
well  be  interpreted  as  weak  places  in  these  dementia  prascox 
brains,  and  the  brains  in  fact  are  apt  to  show  scleroses  and 
atrophic  processes  over  and  above  the  anomalies.  But  certain 
perfectly  normal-looking  brains  in  dementia  prsecox  also  show 
the  same  microscopic  changes  in  lesser  degrees  than  are  found 
in  the  anomalous  sclerotic  and  atrophic  brains.  The  problem  of 
the  present  communication  has  been  to  work  out  the  focality  of 
these  microscopic  lesions  in  a  few  normal-looking  brains  studied 


170 

with  unusual  intensiveness.  In  the  same  series  of  brains,  work 
of  previous  seasons  had  shown  a  dissociation  of  parenchymatous 
(neuronic)  and  interstitial  (neuroglia)  changes,  indicating  a  tend- 
ency on  the  part  of  cortex  pathology  to  resemble  the  pathology 
of  the  kidney.  But  the  majority  of  brains  show  mixtures  of  the 
parenchymatous  (neuronic)  and  the  interstitial  (neuroglia)  lesions. 
Recent  work  in  comparative  anatomy  indicates  the  rather  funda- 
mental importance  of  distinguishing  the  functions  of  the  upper 
cortical  layers  (what  may  be  called  the  supracortex)  from  the 
functions  of  the  lower  cortical  layers  (what  may  be  called  the 
infracortex).  The  finer  processes  of  mental  dissociation  (schizo- 
phrenia) ought  to  be  correlated  with  lesions  of  the  supracortex,  and 
such  lesions  were  found  in  cases  with  evidence  of  schizophrenia. 

On  the  other  hand,  in  a  case  of  delusions  characterized  by  no 
splitting  (schizophrenia)  whatever,  but  rather  by  a  process  of 
overelaborate  synthesis,  there  was  no  evidence  of  supracortical 
disorder,  and,  in  fact,  no  proposal  can  be  made  for  any  histologic 
correlate  with  this  process  of  oversynthesis. 

Other  processes  equally  characteristic  of  dementia  praecox,  but 
logically  far  simpler  in  their  make-up,  such  as  auditory  hallu- 
cinosis and  muscular  hypertension  (catatonia),  received  sugges- 
tive correlation  with  processes  in  the  lower  layers  of  the  temporal 
and  parietal  regions,  respectively. 

As  far  as  the  tissues  of  these  four  cases  go,  there  is  little  or 
nothing  inconsistent  in  the  findings  with  the  hypothesis  that 
ordinary  (non-phantastic)  delusions  are  correlated  with  frontal 
rather  than  with  otherwise  situated  lesions;  but  the  supra- 
cortical  type  of  delusions  found  in  certain  long-standing  para- 
noiacs,  whose  fine  mental  processes  run  in  a  quasi-normal  manner, 
find  no  special  correlation  in  any  region,  and  the  probable  lines 
on  which  this  problem  is  to  be  solved  remain  obscure. 

As  for  auditory  hallucinosis,  the  work  seems  to  afford  the 
expected  correlation  with  temporal  lesions.  In  one  case,  however, 
temporal  lesions  of  considerable  severity  were  not  attended  in 
life  by  hallucinations  of  hearing,  but  in  this  case  there  was  also 
a  severe  supracortical  disease  of  the  temporal  region,  and  it 
may  be  that  for  the  production  of  hallucinations,  some  congress 
is  necessary  between  the  activation  of  the  supracortex  and 
infracortex,  respectively. 

In  previous  work  on  this  series,  the  brains  had  indicated  a  post- 
central and  superior  parietal  correlation  for  catatonia  whose 
muscular  hypertension  was  accordingly  regarded  as  very  possibly 


171 

a  kind  of  morbid  kinesthesia.  Present  work  suggests  that  the 
anatomic  correlate  is  not  merely  to  the  postcentral  and  parietal 
regions,  but  still  more  specifically  to  the  infracortical  parts  of 
these  regions. 

It  may  be  suggested  that  the  lesions  found  in  samples  of  tissue 
in  the  postcentral,  superior  parietal,  inferior  parietal  and  superior 
temporal  regions  indicate  a  certain  systemic  tendency  in  the 
underlying  processes,  for  these  lesions  were  bilateral,  and  occurred, 
as  it  were,  in  two  continuous  sheets  of  tissue  on  both  flanks  of 
the  brain  in  one  of  the  best  defined  of  our  cases;  these  flank 
lesions  were  not  attended  by  any  similar  lesions  of  the  frontal, 
precentral,  occipital  and  lower  temporal  and  smell  regions.  The 
nature  of  a  process  which  could  mildly  affect  nerve  cells  and 
neuroglia  on  two  sides  of  the  brain,  and  also  specially  affect  the 
infracortical  rather  than  the  supracortical  portions  of  these 
affected  sheets  of  tissue,  remains  a  mystery.  It  is  perhaps  no 
greater  mystery  than  that  which  attends  the  distribution  of 
lesions  in  the  spinal  cord  of  pernicious  anemia.  It  remains 
unsettled  whether  these  lesions  are  secondary  in  point  of  time  to 
a  non-cell-destructive  phase  in  the  disease,  or  whether  the  lesions 
of  which  these  microscopic  effects  are  indicators  began  pari  passu 
with  the  symptoms;  that  is,  it  remains  a  question  whether  we 
are  dealing  with  the  excess  wear-and-tear  process  of  cell  mech- 
anisms morbidly  employed,  or  whether  the  morbidity  of  neural 
function  is  an  exact  equivalent  of  the  neuronic  and  neuroglia 
morbidity. 

Southaed,  E.  E.,  and  Solomon,  H.  C.  Neurosyphilis,  Modern 
Systematic  Diagnosis  and  Treatment  presented  in  137  Case 
Histories.     Boston,  1917,  W.  M.  Leonard,  496  pp.,  8°. 

Southard,  E.  E.  Alienists  and  Psychiatrists:  Notes  on  Divi- 
sions and  Nomenclature  of  Mental  Hygiene.  Being 
M.  C.  M.  D.  Contribution  No.  187  (1917.7).  Mental 
Hygiene,  Concord,  N.  H.,  1917,  I,  567-571.  Also  in  Bulletin 
of  Massachusetts  Commission  on  Mental  Diseases,  Boston, 
1917-18,  I,  Nos.  3  and  4,  201-205. 

Conclusions. 
It  is  proposed  that  the  term  alienist  be  used  of  experts  in  the 
forensic   or  medicolegal   subdivision   of  mental   hygiene,   dealing 
with  insanity. 


172 

It  is  proposed  that  the  term  psychiatrist  be  used  of  medical 
experts  concerned  with  mental  diseases. 

As  a  minor  point  in  nomenclature,  it  is  proposed  to  distinguish 
the  alienistics  of  a  case  from  the  psychiatry  thereof.  As  insanity 
stands  /to  mental  disease,  so  alienistics  would  stand  to  psychiatry. 
Alienistics  would  be  primarily  a  branch  of  law;  psychiatry  a 
branch  of  medicine. 

Five  or  six  subdivisions  of  mental  hygiene  are  mentioned  as 
existent   or  developing. 

Public  mental  hygiene  has  the  two  well-established  subdivi- 
sions, institutional  and  medicolegal. 

Social  mental  hygiene  has  produced  effective  social  service.  It 
is  a  question  how  far  character  handicap  work  can  go;  but  there 
are  signs  of  a  specialty  in  mental  hygiene  here  also,  using  practical 
psychiatric,  social-service  and  social-psychological  categories. 

Personal  or  individual  (medical)  mental  hygiene  is  founded  on 
the  achievements  of  practical  psychiatry,  which  may  now  be 
regarded  as  a  specialty  independent  of  institutional  mental 
hygiene  and  of  "alienistics."  But  metric  psychiatry  is  gaining 
ground,  following  the  work  of  Binet,  and  "mental  tests"  promise 
to  be  of  value  not  only  in  "mind-lack"  and  "mind-loss"  ques- 
tions of  practical  psychiatry,  but  also  (at  least  negatively)  in 
the  field  of  character  handicap  work  in  employment  and  voca- 
tional choice. 

Southard,  E.  E.,  and  Solomon,  H.  C.  Notes  on  Gold  Sol 
Diagnostic  Work  in  Neurosyphilis  (Psychopathic  Hospital, 
Boston).  Being  M.  C.  M.  D.  Contribution  No.  165 
(1916.23).  Bulletin  of  Massachusetts  Commission  on 
Mental  Diseases,  Boston,  1917,  I,  Nos.  1  and  2,  254-260. 
Also  in  Journal  of  Nervous  and  Mental  Disease,  New  York, 
1917,  XLV,  230-236. 

Southard,  E.  E.  The  Desirability  of  Medical  Wardens  for 
Prisons.  Being  M.  C.  M.  D.  Contribution  No.  192 
(1917.12).  Proceedings,  National  Conference  of  Social 
Work,  Chicago,  1917,  XLIV,  589-594. 

Southard,  E.  E.  Zones  of  Community  Effort  in  Mental 
Hygiene.  Being  M.  C.  M.  D.  Contribution  No.  193 
(1917.13).  Proceedings,  National  Conference  of  Social 
Work,  Chicago,  1917,  XLIV,  405-413. 


173 


1918. 

Southard,  E.  E.,  and  Canavan,  M.  M.,  M.D.  An  Anatomical 
Search  for ,  Non-tuberculous  Dementia  Prsecox.  (Abstract.) 
Journal  of  Nervous  and  Mental  Disease,  New  York,  1918, 
XL VII,  41.  Also  in  Transactions,  American  Neurological 
Association,  1917,  242. 

Remarks. 
Several  autopsy  collections  in  Massachusetts  institutions  have 
been  searched  for  dementia  prsecox,  and  the  percentages  of  open 
and  closed  tuberculosis  determined.  General  figures  for  the 
whole  series;  dementia  prsecox  patients  are  more  apt  to  die  of 
tuberculosis  than  are  non-dementia  prsecox  patients.  The  demen- 
tia prsecox  group  itself,  defined  by  various  more  or  less  rigorous 
criteria,  has  been  studied  more  narrowly  with  respect  to  tuber- 
culous lesions,  disease  type  and  the  like. 

Southard,  E.  E.  Remarks  on  Advanced  Training  for  Social 
Workers.     Radcliffe  Quarterly,  February,   1917,  35-38. 

Southard,  E.  E.  Remarks  on  the  Progress  of  the  Waverley 
Researches  in  the  Pathology  of  the  Feeble-minded.  Pro- 
ceedings and  Addresses  of  the  Forty-second  Annual  Session 
of  the  American  Association  for  the  Study  of  the  Feeble- 
minded, 1918,  48-59. 

Southard,  E.  E.,  and  Taft,  Annie  E.  Memoirs  of  the 
American  Academy  of  Arts  and  Sciences,  1918,  XIV.  I. 
General  Aspects  of  the  Brain  Anatomy  of  the  Feeble- 
minded (E.  E.  Southard).  II.  Clinical,  Anatomical,  and 
Brief  Histological  Description  of  Ten  Cases  of  Feeble- 
mindedness (Dr.  Southard  and  Dr.  Annie  E.  Taft).  III. 
Neuropathological  Correlations  with  Clinical  and  Psycho- 
metric Findings  in  Feeble-mindedness  (Waverley  Research 
Series  Cases  I-X)  (Dr.  Southard  and  Dr.  Taft). 

Summary. 
The  entirely  provisional  conclusions  of  the  epicritical  review 
may  be  briefly  stated  as  follows :  — 

First.  —  It  is   not  impossible   that   the   problem   of   matching 


174 

brain  complexity  with  mental  capacity  may  be  solved  by  a 
much  larger  series  of  instances  than  is  here  available;  but  the 
instances  of  such  matching  as  has  been  undertaken  are  somewhat 
convincing  as  to  the  correlations  of  •  low  orders  of  intelligence 
with  simple  brains,  and  of  higher  orders  of  intelligence  with  more 
complex  brains.  Occasional  exceptions  to  the  rule  may  be  ex- 
plained by  the  finer  anatomy  of  certain  cases  (Case  IX);  others 
remain  less  easy  to  explain  away  (Case  III). 

Second.  —  The  partial  orienting  and  microscopic  examination 
yielded  more  instances  of  slight  exudative  lesions  (including  in 
some  instances  rod  cells)  than  might  have  been  a  priori,  except 
from  a  relatively  stable  institutional  material  like  that  here 
largely  drawn  upon.  What  the  share  of  syphilis  in  this  group 
of  cases  may  really  be  is  doubtful.  There  was  one  instance  of 
feeble-mindedness  very  possibly  due  to  an  early  focal  encepha- 
litis entailing  maldevelopment  of  brain. 

Third.  —  As  an  example  of  special  neurological  interest  attach- 
ing to  this  study,  some  considerations  about  hydrocephalus 
offered  bring  up  the  question  of  the  relation  between  occasional 
bursts  of  excitability  and  alterations  of  intracranial  pressure 
with  the  production  of  hydrocephalus. 

Southard,  E.  E.  Notes  on  Researches  in  Epilepsy  at  Monson 
State  Hospital,  Massachusetts.  Being  Contribution  No. 
208  (1917.28),  in  Bulletin  of  Massachusetts  Commission  on 
Mental  Diseases,  1918,  II,  No.  21,  10-19. 

Southard,  E.  E.,  and  Canavan,  M.  M.  Notes  on  the  Relation 
of  Tuberculosis  to  Dementia  Prsecox.  Journal  of  Nervous 
and  Mental  Disease,  1918,  XLVIII,  193-200. 

Summary. 
On  account  of  a  recent  revival  of  interest  in  the  relation  be- 
tween tuberculosis  and  dementia  prsecox,  a  brief  statistical 
inquiry  was  made,  using  data  of  the  Massachusetts  autopsy 
series.  It  was  shown  that  dementia  prsecox,  found  in  8  per  cent 
of  5,040  Massachusetts  autopsies,  was  far  more  apt  to  be  termi- 
nated by  tuberculosis  than  manic-depressive  psychosis,  occurring 
in  7  per  cent  of  the  basic  series.  Out  of  403  cases  of  dementia 
prsecox    120   died   of   tuberculosis,    and   but   43    of   339   cases   of 


175 

manic-depressive  psychosis.  Eighty-seven  cases  of  dementia 
praecox  showed  neither  death  due  to  tuberculosis  nor  any  anatom- 
ical feature  whatever  (even  including  adhesions  in  various  parts 
of  the  body),  which  could  conceivably  be  related  with  tubercu- 
losis. Ninety-five  cases  of  manic-depressive  psychosis  were 
equally  free  from  tuberculosis. 

The  question  whether  these  non-tuberculous  cases  of  dementia 
praecox  were  actually  victims  of  the  disease  and  not  subject  to 
erroneous  diagnosis  was  taken  up  in  the  statistical  study  from 
the  Danvers  symptom  catalogue,  from  which  36  cases  dead  of 
tubercle  were  taken  to  contrast  with  27  cases  dying  without  the 
slightest  evidence  of  tuberculosis  whatever.  Some  of  the  most 
characteristic  symptoms  of  dementia  praecox  were  found  equally 
distributed  in  the  two  groups  and  strongly  represented  in  both, 
so  that  no  major  doubt  can  be  raised  as  to  the  accuracy  of  the 
diagnosis  of  dementia  praecox  in  the  non-tuberculous  group.  For 
example,  the  fundamental  symptoms  of  dementia  and  delusions 
of  paranoid  type  are  found  equally  represented  in  both.  Nor 
was  it  found  that  the  fundamental  symptom,  dementia,  was  more 
frequently  shown  in  the  fatally  tuberculous  cases  than  in  the 
others. 

An  interesting  question  is  raised  by  the  distribution  of  hyper- 
kinetic and  catatonic  symptoms.  Tuberculosis  appears  to  dis- 
pose certain  cases  to  catatonia  and  to  hyperkinetic  symptoms  of 
a  presumably  psychogenic  or  cortical  nature.  Per  contra,  the 
non-tuberculous  cases  showed  more  instances  of  the  peripheral 
symptom  —  motor  restlessness  —  than  did  the  tuberculous  cases. 
Can  it  be  true  that  tuberculosis  inclines  the  dementia  praecox 
victim  more  to  catatonia  {central  hyperkinesis)  and  less  (perhaps 
by  processes  of  inhibition)  to  peripheral  forms  of  hyperkinesis 
than  do  the  conditions  that  prevail  in  the  non-tuberculous 
group? 

Another  hypothesis  raised  by  this  statistical  study  is  whether 
tuberculosis  does  not  cause  a  trend  of  symptoms  in  dementia 
praecox  over  toward  manic-depressive  psychosis.  Does  not  the 
superposition  of  a  somatic  feature  like  tuberculosis  upon  the 
encephalic  or  psychogenic  picture  of  dementia  praecox  cause  also 
a  superposition  of  sundry  features  showing  an  alliance  with  those 
of  manic-depressive  psychosis?  Or,  put  more  briefly,  does  not 
tuberculosis  tend  to  make  dementia  praecox  look  more  at  times 
like  manic-depressive  psychosis  than  dementia  praecox  is  ordi- 
narily likely  to  look? 


176 

Southakd,  E.  E.  The  Kingdom  of  Evil:  Advantages  of  an 
Orderly  Approach  in  Social  Case  Analysis.  Proceedings, 
National  Conference  of  Social  Work,  Chicago,  1918,  XLV, 
334-340. 

Southard,  E.  E.  Suggestions  in  the  Nomenclature  of  the 
Feeble-mindednesses.  Mental  Hygiene,  Concord,  N.  H., 
1918,  II,  605-610. 

Southard,  E.  E.  Shell  Shock  and  After.  (The  Shattuck 
Lecture.)  Boston  Medical  and  Surgical  Journal,  1918, 
CLXXIX,  73-93.  Being  Contribution  No.  268  (1918.8), 
in  Bulletin  of  Massachusetts  Commission  on  Mental  Dis- 
eases, III,  No.  2,  1919,  pp.  5-43. 

Southard,  E.  E.  Mental  Hygiene  and  Social  Work:  Notes  on 
a  Course  in  Social  Psychiatry  for  Social  Workers.  Mental 
Hygiene,  Concord,  N.  H.,  1918,  II,  388-406. 

Summary. 

Some  reflections  have  been  put  together  on  a  course  for  social 
workers  on  social  psychiatry  recently  given  in  Boston.  These 
reflections  deal  largely  with  some  distinctions  between  mental 
hygiene  and  social  service.  Mental  hygiene  is  regarded  as  a 
branch  of  medicine,  in  a  sense  co-ordinate  with  the  psychiatric 
branch  of  social  work. 

At  first,  the  distinctions  between  mental  hygiene  and  psychi- 
atric social  work  are  very  clearly  and  definitely  drawn.  Particu- 
lar emphasis  is  laid  upon  the  individualism  of  the  point  of  view 
of  mental  hygiene  as  against  the  groupism  of  social  workers.  But 
in  the  end  it  is  pointed  out  that  if  mental  hygienists  are  to  ob- 
tain auxiliaries,  such  as  every  expert  eventually  obtains  in  the 
evolution  of  his  art,  these  mental  hygiene  aides  will  probably  be 
best  drawn  from  the  ranks  of  the  social  workers;  they  will  be  a 
kind  of  specialized  and  advanced  social  worker. 

The  point  is  that  as  the  mental  hygienist  advances  from  the 
individual  to  the  family  and  thence  to  the  community,  so  the 
social  worker,  at  first  aiming  at  the  community,  focalizes  upon 
the  family,  and  finally  gets  a  point  of  view  concerning  the  indi- 
vidual not  far  from  that  entertained  by  the  mental  hygienist. 

Despite    the   logical    differences,    then,    between    the    point    of 


177 

view  of  mental  hygiene  and  that  of  social  work  (logical  differ- 
ences which  it  is  well  to  bring  out  when  endeavoring  to  get  the 
medical  point  of  view  to  some  extent  over  into  the  minds  of  the 
social  workers),  there  will  be  in  practice  little  doubt  that  mental 
hygienists  will  find  some  of  their  most  valuable  aides  in  specially 
trained  social  workers.  Just  as  the  orthopedists  will  use  nurses 
and  others  skilled  in  physical  therapy,  and  just  as  the  vocation 
workers  will  use  persons  specially  trained  in  invalid  occupation 
and  in  handicraft  teaching,  so  the  mental  hygienists  in  war  time 
will  crave  the  aid  of  specially  trained  social  service  auxiliaries; 
that  is,  mental  hygiene  aides  that  have  been  given  special  training. 

In  the  Boston  course,  largely  for  advanced  social  workers  who 
had  all  had  a  pretty  definite  curriculum,  stress  was  laid  upon 
sundry  methods  of  analysis  of  social  data  after  their  collection. 
Among  these  methods  of  analysis  was  one  which  took  up  the 
question  of  the  public,  social  and  personal  aspects  of  whatever 
problem  of  maladjustment  was  in  question.  Another  dealt  with 
the  analysis  of  the  patient's  subjective  attitude  to  his  environ- 
ment and  himself,  —  a  question  of  the  passive  voice.  A  third 
dealt  with  a  method  of  analyzing  data  from  the  standpoint  of  the 
evils  found  in  evidence,  and  for  the  purpose  of  orderly  analysis 
a  tentative  rough  classification  of  the  kingdom  of  evil  was  given. 

In  view  of  war  contingencies,  brief  suggestions  have  been 
made  as  to  the  desirable  content  of  courses  for  psychiatric  social 
workers  of  value  in  war  time  and  after. 

Southard,  E.  E.  Insanity  versus  Mental  Diseases.  The  Duty 
of  the  General  Practitioner  in  Psychiatric  Diagnosis.  Ab- 
breviated in  Journal  of  American  Medical  Association, 
1918,  LXXI,  1259-1264.  Published  in  full  in  the  Trans- 
actions of  the  Section  on  Nervous  and  Mental  Diseases  at 
the  Sixty-ninth  Annual  Session  of  the  American  Medical 
Association,  Chicago,  June,  1918.  Also  (Abstract)  in  Journal 
of  Nervous  and  Mental  Disease,  1919,  XLIX,  371,  372. 

Conclusions. 

1.  The  advance  of  the  mental  hygiene  movement  throws  more 
responsibilities  in  psychiatric  diagnosis  on  the  general  prac- 
titioner. 

2.  The  general  practitioner  should  bring  his  specialistic  knowl- 
edge of  psychiatry  up  level  with  his  specialistic  knowledge,  in 
ophthalmology  and  dermatology,  for  example. 


178 

3.  Alienists  are  to  be  distinguished  from  psychiatrists,  and 
forensic  psychiatry  ("alienistics")  from  practical  psychiatry,  in 
certain  ways  (Table  1). 

4.  There  is  at  present  great  unanimity  on  the  part  of  American 
specialists  in  mental  disease,  as  indicated  by  the  adoption  of 
common  statistical  forms  (American  Medico-Psychological  Asso- 
ciation). 

5.  For  arriving  at  a  diagnosis  of  mental  disease,  I  suggest  an 
arbitrary  order  of  exclusion  by  eleven  great  groups,  into  which 
I  have  thrown  the  accepted  entities. 

6.  Nomenclature  divergences  are  much  more  frequent  than 
divergences  on  facts. 

7.  The  use  of  Bleuler's  term  "schizophrenia"  for  dementia 
prsecox,  and  of  the  term  (in  cognate  use)  "cyclothymia"  for 
manic-depressive  psychosis,  is  advocated  in  the  line  of  exactitude 
and  the  ready  formation  of  adjectives  and  relative  terms. 

8.  The  use  of  a  new  term  "hypophrenia"  for  the  various 
feeble-mindednesses  is  advocated. 

9.  The  ending  "osis"  is  in  general  advocated  for  the  larger 
groups  of  mental  diseases,  parallel  with  the  use  of  "  acece"  and 
"oscc"  for  botanical  orders. 

10.  A  tentative  list  of  "genera"  under  these  orders  is  given  in 
the  text. 

Southard,  E.  E.  The  Training  School  of  Psychiatric  Social 
Work  at  Smith  College;  II.  A  Lay  Reaction  to  Psychiatry. 
Mental  Hygiene,  Concord,  N.  H.,  1918,  II,  584,  585. 

Southard,  E.  E.  Diagnosis  per  Exclusionem  in  Ordine:  General 
and  Psychiatric  Remarks.  Journal  of  Laboratory  and 
Clinical  Medicine,  St.  Louis,  1918,  IV,  31-54.  Also  in 
Transactions,  Association  of  American  Physicians,  Phila- 
delphia, 1918,  XXXIII,  267-301.  Being  Contribution 
(1917.53)  in  Bulletin  of  Massachusetts  Commission  on 
Mental  Diseases,  1918,  II,  No.  3,  90-122. 

Summary. 

1.  The  writer  apologizes  for  a  communication  on  medical  logic 

in   general  when  he  is   only   a  psychiatrist  and   but  recently  a. 

pathologist.     His  excuse  is  the  necessity  for  reasonably  accurate 

snap  diagnosis  in  the  sifting  problem  of  the  psychoses,  psycho- 


179 

neuroses  and  psychopathias,   as  they  flow  through  the  Psycho- 
pathic Hospital  clinic  in  Boston. 

2.  The  medical  student  is  found  destitute  of  the  ability  to 
define  entities  and  symptoms.  The  textbooks  in  medicine, 
especially  the  single  volume  textbooks,  rather  tend  to  make  the 
student  believe  that  diagnosis  is  observation.  In  point  of 
fact,  diagnosis  is  not  observation,  though  it  requires  and  indeed 
stands  or  falls  by  accurate  observation. 

3.  Da  Costa  and  his  successors  have  lauded  so-called  direct 
diagnosis  to  the  skies,  and  Da  Costa  rather  decried  indirect 
diagnosis  by  exclusion  as  a  tedious  process.  An  example  is  cited 
from  Da  Costa  which  shows  how  relatively  simple  the  classical 
diagnoses  of  general  medicine  are  beside  those  of  psychiatry. 

4.  It  seemed  that  diagnosis  by  exclusion  ought  to  be  rehabili- 
tated. An  examination  of  recent  research  work  in  logic  indicated 
that  higher  and  more  complex  methods  than  those  of  observation 
had  become  necessary  in  science.  For  example,  Cabot  and  Her- 
bert French  have  attempted  to  profit  by  the  statistical  method, 
which  again,  though  it  requires  reasonably  accurate  observation, 
is  not  in  itself  a  method  of  observation  at  all.  Yet  Cabot's 
statistical  frequency  tables  possess  a  certain  diagnostic  value. 
But  the  student  is  often  misled  by  the  brilliancies  of  so-called 
observational  diagnosis  in  a  clinic.  Here  diagnoses  are  often 
rendered  on  inspection  by  a  process  akin  to  the  recognition  of  a 
fruit  as  an  orange,  or  an  automobile  trouble  as  "the  engine  is 
skipping."  This  process  is  not  diagnosis,  it  is  a  process  of  recog- 
nition that  may  receive  a  simpler  term  gnosis. 

5.  The  offhand  snap  diagnostic  work  at  the  Psychopathic 
Hospital  indicated  that  we  were  in  practice  relying  upon  the 
successive  exclusion  of  certain  great  disease  groups  in  a  certain 
definite  order. 

6.  A  study  of  Royce's  "Summary  of  Recent  Researches  in 
Logic"  shows  how  an  organized  combination  of  theory  and 
experience  is  the  higher  logic  to  which  the  more  complicated 
sciences  must  resort.  Royce  himself  mentioned  psychiatry  as  a 
science  about  to  climb  out  of  the  classifying  era  into  the  era  of 
logical  order,  that  is,  of  the  organized  combination  of  theory  and 
experience.  Such  a  dictum  as  that  "disease  is  life  under  altered 
conditions"  seems  now  childishly  simple.  The  idea  that  disease 
is  a  matter  of  an  organism  plus  a  germ  was  found  to  be  altogether 
too  simple  when  in  the  nineties  of  the  last  century  the  concepts 
of  immunology  were  developed. 


180 

7.  Those  departments  of  medicine  in  which  the  presenting 
symptom  of  Richard  Cabot  is  of  value  are  lucky  departments. 
Those  departments  of  medicine  in  which  the  indices  of  disease,  or 
indicator  symptoms  of  the  elder  writers  are  available,  are  also 
fortunate  departments  in  comparison  with  psychiatry.  In 
mental  disease  there  are  exceedingly  few  indicator  symptoms. 

8.  Hence  the  need  became  apparent  of  a  process  of  exclusion  of 
great  groups  or  phenomena  in  a  certain  definite  order,  so  that 
nothing  of  large  significance  should  evade  consideration.  To 
avoid  the  tediousness  of  exclusion,  complained  of  by  Da  Costa, 
the  phenomena  of  disease  had  to  be  logically  grouped  in  certain 
great  groups,  and  the  process  types  of  diagnosis  in  the  books  may 
be  counted  as  six  or  eight,  according  to  definition. 

9.  In  the  body  of  the  paper,  a  special  statement  was  made 
about  each  of  these  process  types:  inspection  (regarded  as  not 
really  diagnosis  but  as  merely  recognition  of  gnosis);  expecta- 
tion, a  newly  named  but  frequent  method  (far  older  than  Mi- 
cawber);  induction,  ex  juvantibus,  ex  nocentibus  (three  methods 
in  which  in  no  very  rigorous  way  experiment  is  used);  and  these 
three  methods  of  diagnosis  by  comparison  are  successively  dis- 
cussed. 

10.  The  ninth  method,  diagnosis  per  exclusionem  in  ordine,  is 
in  one  sense  a  minor  modification  of  the  old  method  of  diagnosis 
by  exclusion.  It  is  of  value  in  departments  of  medicine,  where 
there  are  no  indicator  symptoms,  and  where  the  so-called  pre- 
senting symptom  would  merely  indicate  some  kind  of  mental 
disease. 

11.  The  general  application  of  the  method  of  diagnosis  per 
exclusionem  in  ordine  in  the  field  of  mental  disease  is  demon- 
strated in  the  eleven  groups  of  mental  diseases  into  which  most 
of  the  phenomena  may  be  pragmatically  cast.  The  groupings 
are  not  by  clinical  resemblances,  by  anatomical  attack  or  by 
etiology.  The  distinction  is  a  pragmatic  and  therapeutic  one, 
and  will  naturally  tend  to  become  more  and  more  etiologic  as 
the  causes  are  determined.  But  in  the  field  of  mental  disease, 
causes  are  so  apt  either  to  be  unknown  or  to  be  multiple  that 
etiologic  classification  on  any  simple  basis,  such  as  that  of  the 
infectious  diseases,  is  practically  inconceivable. 

12.  It  is  hoped  that  other  departments  of  medicine  (where 
diagnosis  is  raised  above  the  level  of  mere  recognition,  and  where 
there  are  few  or  no  pathognomonic  or  indicator  symptoms),  will 
find  it  to  their  advantage  to  set  up  a  method  of  diagnosis  per 


181 

exclusionem  in  ordine,  the  great  groups  or  orders  being  always 
determined  on  a  pragmatic  basis.  In  the  body  of  the  paper  are 
given  the  general  designations  of  the  ten  great  groups  of  mental 
diseases,  with  the  eleventh  residual  group. 

Southard,  E.  E.  The  Empathic  Index  in  the  Diagnosis  of 
Mental  Diseases.  Journal  of  Abnormal  Psychology,  Boston, 
1918,  XIII,  199-214. 

Canavan,  M.  M.,  and  Southard,  E.  E.  Microlienia  and  Other 
Observations  on  the  Spleen  in  Psychopathic  Subjects. 
Being  M.  C.  M.  D.  Contribution  No.  236  (1917.56).  Bulle- 
tin of  Massachusetts  Commission  on  Mental  Diseases, 
1918,  II,  136-142. 

Summary. 

1.  Microlienia  is  frequent  in  the  bodies  of  psychotic  subjects. 

2.  Possibly  this  small  spleen  is  an  index  of  general  hypo- 
lymphatism  in  the  body.  At  all  events,  it  is  correlated  with 
these  mucous  membranes  and  with  a  small  amount  of  lymph 
node  tissue  in  a  large  number  of  instances.  The  "psychotic" 
spleen-liver  index  was  112  to  1,362,  as  against  normal,  171  to 
1,500. 

3.  Chronic  lesions  are  frequent,  for  example,  15  per  cent  of 
lesions  in  the  capsule;  28  per  cent  of  lesions  in  the  tunica 
albuginea;  12  per  cent  of  thickenings  in  the  trabeculee;  67  per 
cent  of  plasma  cells  in  the  pulp  cords;  and  86  per  cent  of 
thickenings  in  the  arterial  twigs. 

4.  The  high  degree,  67  per  cent,  of  plasma  cells  in  the  pulp 
cords  seems  of  importance  when  it  is  considered  that  some 
authors  feel  that  plasma  cells  in  the  spleen  have  pathological 
significance.  v 

5.  A  similar  study  of  kidney  lesions  in  the  same  series,  pub- 
lished in  1914,  showed  but  42  per  cent  of  plasma  cells  in  the 
kidney. 

6.  As  for  the  malpighian  bodies,  considerable  variations  in  the 
number  of  rows  of  cells  was  found  therein,  3  to  30. 

7.  Whether  this  hypolienia  has  anything  to  do  with  reactions 
of  psychotic  subjects  to  infection  must  remain  doubtful. 

8.  It  would  appear  that  further  studies  of  the  hemopoietic 
system   ought  to   be   made  in   the   psychoses   and   ought   to   be 


182 

supported   by   accurate   clinical   studies   of  the  peripheral   blood 
intra  titam. 

9.  Eighteen  spleens  of  general  paretics  were  carefully  studied 
for  spirochetosis;    no  spirochetes  were  found. 

Southard,  E.  E.  Discussion  on  Illness  in  Industry  —  Its  Cost 
and  Prevention.  Transactions,  American  Institute  of 
Mining  Engineers,  1918,  LIX,  678-684. 

1918-19. 

Southard,  E.  E.  A  Key  to  the  Practical  Grouping  of  Mental 
Diseases.  Being  M.  C.  M.  D.  Contribution  No.  196 
(1917.16).  Journal  of  Nervous  and  Mental  Disease,  1918, 
XLVII,  1-19.  Also  in  Bulletin  of  Massachusetts  Commis- 
sion on  Mental  Diseases,  Boston,  1918-19,  II,  No.  1,  5-24. 

Summary  and  Conclusions. 

I  have  here  presented  not  so  much  a  classification  as  a  key  to 
the  grouping  of  mental  diseases.  The  key  has  been  worked  out 
to  the  extent  of  ten  well-defined  groups  and  an  eleventh  residual 
group.  These  groups  correspond  to  the  groups  of,  e.g.,  the 
Rosacea?  or  Leguminosa?  of  botany,  and  do  not  correspond  to  the 
genera  and  species  of  those  orders.  Some  hint  is  given  of  the 
generic  and  specific  distinctions  of  mental  disease  that  might 
correspond  to  the  genera  and  species  of  botany,  provided  that 
there  were  any  practical  need  for  a  quasi-botanical  or  zo-ological 
genus-species  distinction  in  mental  diseases. 

The  incentive  to  this  grouping  has  been  practical.  No  en- 
deavor was  made  on  the  library  table  to  construct  a  hortus  siccus 
of  mental  diseases.  On  the  contrary,  this  key  is  the  product  of 
several  years  of  work  in  the  Psychopathic  Hospital  in  Boston, 
where  the  task  of  reasonably  accurate  diagnosis  by  an  ever- 
changing  staff  of  psychiatrists  in  training  was  the  desideratum. 
I  do  not  accordingly  suggest  this  key  as  something  to  replace 
the  methods  of  the  expert  in  arriving  at  a  conclusion  concerning 
psychiatric  diagnosis.  I  do  offer  it,  however,  as  a  guide  for  the 
tyro  and  the  psychiatrist  in  training.  It  is  not  an  outline  giving 
an  order  of  examination.  It  is  a  scheme  for  summarizing  arid 
evaluating  results  after  the  physical,  mental  and  historical  data 
are  collected.  The  plan  is  eliminative,  but  is  subject  to  this 
reservation:    if  one  arrives  in  the  chosen  sequence  of  analysis  at 


183 

a  plausible  or  even  a  correct  group  diagnosis,  one  is  not  thereby 
absolved  from  continuing  the  process  of  analysis.  All  data  bear- 
ing on  any  of  the  groups  must  be  considered.  Diseases  may  be 
"hybrid,"  though  practically  one  is  almost  never  in  doubt  as  to 
the  group  under  which  to  subsume  a  case.  Theoretically,  one 
may  be,  for  example,  both  epileptic  and  alcoholic;  practically 
one  is  either  an  epileptic  alcoholic  or  an  alcoholic  epileptic.  The 
guide  to  the  grouping  here  is  a  pragmatic  one,  and  depends  upon 
the  institution  or  the  special  treatment  to  which  the  supposed 
victim  of  epilepsy  and  alcoholism  must  gravitate.  I  must  es- 
pecially emphasize  that  the  groups  and  the  group  names  do  not 
correspond  to  nosological  entities  and  entity  names.  The  placing 
of  a  case  in  one  of  these  eleven  groups  is  not  psychiatric  diagnosis 
in  the  entitative  sense.  Accordingly,  this  grouping  does  not  run 
into  collision  with  any  previous  endeavor  to  classify  the  genera 
and  species  of  mental  disease,  such,  for  example,  as  the  genera 
and  species  in  the  majority  of  classifications  quoted  in  Hosack.1 

I  would  insist,  further,  that  the  group  headings  given  are  not 
special  enough  to  constitute  sufficient  diagnosis  for  a  classifica- 
tion of  use  in  the  statistics  of  institutions  for  the  insane.  The 
plan  is  not  so  much  an  excursion  in  nosology  as  an  essay  in  the 
technique  of  psychiatric  diagnosis  for  the  tyro.  The  plan  gives 
hints  for  a  method  of  arriving  at  an  eventual  diagnosis:  it  does 
not  prescribe  the  names  of  diseases.  Again,  the  plan  is  not  an 
etiological  plan,  although  recent  advances  in  psychiatric  etiology 
have  been  such  that  many  of  the  practical  groups  are  actually 
etiological  groups. 

It  is  possible  that  the  sequence  has  been  unduly  telescoped. 
It  is  possible  that  there  should  be  a  traumatic  and  an  arterio- 
sclerotic group.  I  have  placed  both  of  these  groups  in  the  en- 
cephalopathic  or  coarse  brain,  or  "neurologist's"  group,  feeling 
that  I  do  the  diagnostic  tyro  a  service  by  pulling  the  encephalo- 
traumatic  psychoses  far  apart  from  the  traumatic  psychoneuroses 
on  the  one  hand,  and  the  arteriosclerotic  psychoses  far  apart 
from  the  senile  psychoses  on  the  other  hand. 

Lastly,  I  would  insist  once  more  that  the  plan  is  one  born  of 
Psychopathic  Hospital  experience  and  bred  in  the  first  place  for 
the  inexpert.     It  is  a  key  to  study  and  not  an  analytical  classi- 

1  Hosack,  David,  "A  System  of  Practical  Nosology:  to  which  is  prefixed  A  Synopsis  of  the 
Systems  of  Sauvages,  Linnaeus,  Vogel,  Sagar,  Macbride,  Cullen,  Darwin,  Crichton,  Pinel,  Parr, 
Swediaur,  Young  and  Good,  with  References  to  the  Best  Authors  on  each  Disease,"  1st  edition, 
1819,  2d  edition,  1821,  New  York. 


184 

fication  with  any  pretense  to  finality.  Elements  in  the  sequence 
can  be  destroyed  and  new  elements  inserted.  Indeed,  such  proc- 
esses of  extrapolation  and  interpolation  must  needs  occur  in 
the  progress  of  practical  diagnosis.  Whatever  novelty  the  plan 
may  have  lodges  in  the  sequential  character  of  the  analysis 
of  data  already  collected,  and  not  in  the  completeness  or  ultimacy 
of  the  groups.  The  sequential  plan  of  analysis  is  of  course  as 
old  as  the  diagnostic  hills.  It  is  superior,  however,  to  the  type- 
matching  method  of  diagnosis  in  vogue  with  many  tyros,  who 
very  often  come  to  their  superiors  with  the  plaint  that  the  data 
in  a  given  case  fit  the  book  descriptions  of  half  a  dozen  diseases. 
A  set  sequential  analysis  of  collected  data  must  be  superior  to 
a  hit-or-miss  type-matching  of  entities. 

Southard,  E.  E.  Recent  American  Classifications  of  Mental 
Diseases.  American  Journal  of  Insanity,  Baltimore,  1918- 
19,    LXXV,   331-349. 

Summary. 
We  thus   arrive   at  the  following   general   considerations   con- 
cerning the  recent  American  classifications  in  psychiatry:  — 

1.  There  is  an  extraordinary  unanimity  on  the  part  of  American 
psychiatrists  as  to  the  constituents  of  psychiatric  nosology,  and 
this  despite  a  number  of  nomenclatural  divergences. 

2.  The  classification  proposed  by  the  American  Medico-Psycho- 
logical Association  and  adopted  by  the  United  States  government 
for  practical  war  work  is  a  suitable  reference  table  for  statistical 
purposes  of  the  major  groups  and  clinical  types  of  mental  disease. 

3.  The  classification  may  be  somewhat  inadequate  for  the  pur- 
pose of  general  and  psychopathic  hospital  practice,  but  a  slight 
revamping  might  solve  this  difficulty. 

4.  The  American  Medico-Psychological  Association's  classifica- 
tion appears  to  follow  an  etiological  ordering  borrowed  ultimately 
from  reputable  German  sources,  and  this  etiological  ordering  is  a 
good  one  if  a  certain  etiological  viewpoint  is  in  mind. 

5.  The  question  is  raised,  Whether  it  would  not  be  better  to 
order  the  groups  and  types  of  mental  disease  in  a  pragmatic 
rather  than  a  theoretical  order,  that  is,  in  an  order  having 
therapy  in  mind  rather  than  an  order  having  etiology  in  mind? 

6.  The  writer  proposes  such  a  pragmatic  order  of  certain  great 
groups  or  orders  of  mental  disease,  corresponding  with  the  botani- 
cal or  zo-ological  orders. 


185 

7.  The  writer  finds  that  the  22  American  Medico-Psychological 
Association's  groups  might  well  be  compressed  for  practical  pur- 
poses of  diagnosis  into  11  groups.  He  finds  that  the  clinical  types 
subordinated  to  the  great  groups  of  the  American  Medico-Psycho- 
logical Association's  classification  correspond  more  or  less  ac- 
curately to  the  genera  of  a  botanical  or  zo-ological  classification, 
and  proposes  that  in  practice  these  sub-groups  be  considered  in 
order,  in  general  accordance  with  the  principles  of  botanical  or 
zo-ological  taxonomies. 

8.  This  question  of  how  to  use  a  classification  may  be  defined 
as  the  question  of  a  key  to  the  grouping  of  diseases.  The  key 
question  is  entirely  independent  of  the  classification  or  reference- 
table  of  entities  and  entity  groups,  and  both  the  key  question  and 
the  classification-list  question  are  independent  of  questions  of 
nomenclature  and  terminology.  Moreover,  the  writer  would 
insist  that  the  logical  process  of  diagnosis  per  exclusionem  in 
ordine  here  developed  has  nothing  whatever  to  do  with  the  order 
in  which  data  can  or  should  be  collected. 


1919. 

Southard,  E.  E.  Shell  Shock  and  Other  Neuropsychiatric 
Problems  presented  in  589  Case  Histories  from  the  War 
Literature,  1914-18.  With  a  Bibliography  by  Norman 
Fenton,  S.B.,  A.M.,  and  an  Introduction  by  Charles  K. 
Mills,  M.D.,  LL.D.     W.  M.  Leonard,  Boston,  1919. 

Southard,  E.  E.  The  Functions  of  a  Psychopathic  Hospital. 
Canadian  Journal  of  Mental  Hygiene,  Toronto,  Ont.,  1919, 
I,  4-19. 

Southard,  E.  E.  Prothymia:  Note  on  the  Moral  Concept  in 
Xenophon's  "  Cyropedia."  Contributions  of  Medical  and 
Biological  Research,  Osier,  1919,  II,  786-795.  Also  (Ab- 
stract) in  Journal  of  Nervous  and  Mental  Disease,  1919, 
I,  63. 

Conclusions. 

1.  The  material  in  Xenophon's  "Cyropedia"  indicates  the 
probable  great  value  of  a  historical  study  of  the  morale-concept, 
—  a  study  that  might  enliven  the  ethics  of  the  day. 

2.  The  itemizing  of  morale-measures  found  in  the  "Cyropedia" 


186 

indicates   the   probable   success   of   a   behavioristic   version   of  a 
large  part  of  morale  as  the  Greeks  saw  it. 

3.  In  particular,  the  roots  of  most  of  the  words  employed  in 
Xenophon's  morale-description  are  roots  having  to  do  with  move- 
ment and  speed  (rather  than  with  mere  strength  statistically 
taken),  and  having  little  to  do  with  mere  feelings. 

4.  In  particular,  also,  many  of  the  words  indicate  the  thoracic 
seat  of  the  motions  engaged  (e.g.,  the  early  localization  of  #17-10'?, 
aniwius,  strong  feeling  and  passion,  derived  probably  from  Ova), 
rush)  rather  than  a  seat  in  the  head  or  in  the  muscular  system  at 
large;  i.e.,  morale  of  Xenophon's  description  is  more  a  matter  of 
heart  than  of  brawn  or  of  head,  but  "heart"  gets  a  behavioristic 
accounting  rather  than  one  in  terms  of  felt  emotion. 

5.  The  morale  of  Xenophon's  day,  or  at  least  the  morale  of 
his  account  in  the  "  Cyropedia,"  is  plainly  far  from  a  complete 
story  of  morale  in  the  modern  sense,  especially  the  morale  de- 
velopments in  armies  and  nations  subsequent  to  the  French 
Revolution. 

6.  The  term  prothymia  is  indicated  for  the  morale  situation  as 
depicted  by  Xenophon.     This  term  has  several  advantages:  — 

(a)  The  root  is  a  leading  term  in  Xenophon's  list. 

(b)  The  root  word  6v/jl6s  has  deep-lying  hints  of  motion  in 
it,  as  well  as  general  usage  in  compounds  suggesting  "heart"  in 
a  figurative  sense;  and  the  prefix  irpo  has  suitable  intimations 
of  pushing  forward  in  space. 

(c)  Modern  psychiatry  has  come  to  use  the  theme  thymia  in 
many  compounds  describing  variants  of  emotion  (e.g.,  hyper- 
thymia,  parathymia). 

(d)  The  term  prothymia  is  euphonious  and  readily  suggests 
variants,  e.g.,  prothymic  (adjective  to  be  used  of  morale  proce- 
dures) and  prothymics  (substantive  for  the  art  of  morale,  or  for 
our  accumulation  of  facts  concerning  morale). 

Southard,  E.  E.  The  Individual  versus  the  Family  as  a  Unit 
of  Interest  in  Social  Work.  Mental  Hygiene,  Concord, 
N.  H.,  1919,  III,  436-444.  Also  in  Proceedings,  National 
Conference  of  Social  Work,  1919,  LXVI,  582-587. 

Southard,  E.  E.  The  Range  of  the  General  Practitioner  in 
Psychiatric  Diagnosis.  Journal  of  American  Medical  Asso- 
ciation, Chicago,  1919,  LXXIII,  1253-1256. 


187 


Summary. 

Psychiatry  has  become  almost  more  popular  with  non-medical 
mental  hygienists  than  the  medical  profession.  Of  course,  the 
relations  that  are  ultimately  to  stand  between  clinical  neurology 
and  psychiatry  are  not  entirely  clear.  But  the  relations  between 
psychiatry  and  the  general  practice  of  medicine  are  disturbed  by 
special  difficulties,  e.g.,  phobias  on  the  part  of  the  general  prac- 
titioner concerning  nomenclature  and  concerning  his  own  sup- 
posed ignorance  of  psychiatry. 

A  frontal  attack  is  proposed  on  the  general  practitioner,  in 
addition  to  the  flank  attacks  considered  desirable  in  the  past, 
for  his  proper  postgraduate  education. 

Psychiatry  is  more  a  synthetic  art  than  is  clinical  neurology, 
now  predominantly  analytic.  But,  being  synthetic,  psychiatry 
has  much  in  common  with  general  medicine.  General  medicine, 
psychiatry,  and  (to  a  certain  point)  obstetrics  treat  the  patient 
as  an  individual,  whereas  the  majority  of  the  specialties  treat  the 
patient  (in  scholastic  phrase)  as  a  dividual. 

The  body  of  the  text  contains  material  illustrative  of  some  in- 
adequacies of  the  general  practitioner  re  psychiatry.  Many  of 
these  are  easily  reparable. 

Southard,  E.  E.  Non-dementia  Non-praecox;  A  Note  on  the 
Advantages  to  Mental  Hygiene  of  extirpating  a  Term. 
(Abstract.)  Journal  of  Nervous  and  Mental  Disease,  New 
York,  1919,  I,  251,  252. 

Note. 

Dr.  E.  E.  Southard  spoke  in  regard  to  the  unsuitableness  of 
the  term  "dementia  praecox"  furnished  by  Kraepelin,  upon  the 
badness  of  which  term  all  are  agreed.  Some  international  com- 
mittee on  psychiatric  terminology  should  be  formed  to  select 
desirable  psychiatrical  terms. 

Neither  dementia  nor  praecox  are  indispensable  features  of 
what  is  called  dementia  praecox.  The  use  of  the  term  brings  un- 
happiness  to  patients  and  much  wrong  results  from  its  use. 
Catatonia  was  first  described  in  1858.  In  1896  Kraepelin  used 
the  term  dementia  praecox  to  include  several  types  of  mental 
disease.  In  1913  he  evolved  thirteen  types,  containing  nine 
types  of  dementia  praecox  and  four  of  paraphrenia,  and  desig- 
nated these  thirteen  types  as  endogenous  deterioration.     Bleuler 


188 

later  suggested  that  schizophrenia  should  be  used  instead  of  the 
undesirable  term  dementia  prsecox.  This  conveys  the  idea  most 
important  to  this  disease,  the  splitting  of  the  personality,  and  it 
forms  a  good  basis  for  various  derivations.  It  does  not  commit 
one  to  any  one  notion  of  the  mechanism  involved  nor  of  the 
nature  of  the  process. 

Southard,  E.  E.  The  Activities  of  the  War  Work  Committee 
of  the  National  Society  for  Mental  Hygiene.  (Abstract.) 
Journal  of  Nervous  and  Mental  Disease,  New  York,  1919, 
XLIX,  44,  45. 

Note. 
Dr.  E.  E.  Southard  was  absent  from  the  meeting,  and  the 
secretary  of  the  society  read  a  few  notes  from  him  on  these 
activities,  in  which  he  outlined  the  early  organization  of  the  War 
Work  Committee  by  Dr.  Bailey,  now  Lieutenant-Colonel,  and 
Dr.  Salmon,  now  Major,  aiming  at  both  unity  of  action  and 
speed  in  the  mobilization  of  the  neuro-psychiatric  and  psycho- 
logical resources  of  the  country.  He  mentioned  the  work  of  the 
psychologists  at  the  cantonments  in  the  examination  of  the 
soldiers  and  officers,  and  in  the  testing  for  defectives,  and  also 
the  work  of  the  neuro-psychiatric  units  in  the  army.  The  results 
of  the  examinations  of  the  latter  group  had  resulted  by  January, 
1918,  in  the  elimination  of  8,000  men  from  active  military  duty 
as  unfits.  Dr.  Southard  emphasized  the  fact  that  this  country  is 
the  first  to  attempt  elimination  of  nervously  unfit  from  the  army 
activities  by  examinations  for  evidences  of  such  inadequacy.  He 
spoke  of  the  great  need  for  men  trained  in  this  field,  noting  that 
over  300  men  had  already  been  commissioned  in  the  army  for 
this  work,  New  York  and  Massachusetts  leading  all  other  States 
in  the  number,  proportionate  and  absolute,  of  men  to  enlist  from 
the  State  institutions.  He  said  that  there  was  also  a  great  need 
of  male  nurses  for  the  work,  reconstruction  aides,  social  service 
workers,  a  necessity  for  provisions  for  the  care  of  the  families  of 
men  entering  the  service,  and  similar  problems  to  which  the  War 
Work  Committee  is  now  devoting  its  energy  and  time. 

Southard,  E.  E.  Sigmund  Freud,  Pessimist.  Journal  of  Ab- 
normal Psychology,  1919,  XIV,  197-216.  Also  (Abstract) 
in  Journal  of  Nervous  and  Mental  Disease,  New  York, 
1919,  I,  162,  163. 


189 

Southard,  E.  E.  The  Genera  in  Certain  Great  Groups  or 
Orders  of  Mental  Disease.  Archives,  Neurology  and  Psy- 
chiatry, 1919,  I,  95-112. 

Summary. 

In  this  paper  I  have  tried  to  amplify  the  key  to  the  practical 
grouping  of  mental  diseases  presented  to  the  American  Neuro- 
logical Association  in  1917.  I  have  amplified  it  by  proposing 
certain  genera  comprised  under  each  of  the  eleven  major  groups 
of  mental  diseases.  These  genera  have  been  placed  in  the  se- 
quence supposed  to  be  the  pragmatic  sequence  in  which  the  in- 
expert diagnostician  should  seek  to  exclude  successively  the 
various  genera;  in  short,  just  as  the  key  to  the  practical  group- 
ing of  mental  diseases  dealt  in  a  certain  sequence  with  eleven 
major  groups,  so  here  the  diagnostician  is  given  an  idea  as  to  the 
proper  method -of  considering  one  after  another  the  genera  com- 
prised in  each  great  group.  No  endeavor  has  been  made  to  re- 
vamp or  especially  modify  the  ideas  of  psychiatrists  as  to  what 
psychotic  entities  exist.  Finality  cannot  be  hoped  for  either 
theoretically  or  practically.  The  principle  of  diagnosis  per 
exclusionem  in  or  dine  is  the  special  principle  insisted  on.  It  is 
applicable  to  any  diagnostic  problem  after  the  data  of  observation 
are  collected.  True  diagnosis  can  only  take  place  after  sufficient 
data  are  collected,  and  efforts  to  make  diagnoses  early  in  the 
stage  of  collecting  data  are  apt  to  result  in  prejudice. 

The  writer  earnestly  hopes  for  critique  of  his  propositions. 
Such  critique  he  hopes  will  be  separated  into  — 

(a)  Critique  of  the  general  principle  of  diagnosis  per  exclusionem 
in  or  dine. 

(b)  Critique  of  the  genera  chosen  for  the  different  groups. 

(c)  Critique  of  nomenclature. 

But  judging  from  the  world's  experience  in  the  past,  it  is  un- 
likely that  many  persons  will  be  able  to  distinguish  nomenclature 
from  the  objects  named  and  the  method  of  using  a  classification 
from  the  classification  itself.  Herein  some  nomenclatural  sug- 
gestions are  made,  but  they  have  nothing  to  do  with  the  main 
line  of  argument.  Herein  a  certain  classification  is  adopted,  but 
there  is  absolutely  no  pretence  to  originality  therein.  The 
writer's  main  emphasis  is  on  the  pragmatic  principle  of  diagnosis, 
namely,  the  principle  of  diagnosis  by  exclusion  in  order,  which 
principle  will  prove  useful  or  useless  without  regard  to  the 
classification  which  it  endeavors  to  exploit  or  the  nomenclature 
which  it  uses  by  the  way. 


190 


Unpublished. 

Southard,  E.  E.  Artistic  Experience:  Its  Relation  to  Other 
Forms  of  Ecstasy.1 

Southard,  E.  E.  General  Psychopathology.  Psychological 
Bulletin,  1919,  XVI,  187-199. 

Southard,  E.  E.,  Canavan,  M.  M.,  and  Thom,  Douglas  A. 
The  First  Thousand  Autopsies  of  the  Pathological  Service 
of  the  Massachusetts  Commission  on  Mental  Diseases, 
1914-19.  Transactions,  American  Medico-Psychological 
Association,  1919.  (Sent  to  American  Journal  of  Insanity, 
March,  1920.) 

Southard,  E.  E.  An  Attempt  at  an  Orderly  Grouping  of  the 
Feeble-mindednesses  (Hypophrenias)  for  Clinical  Diagnosis.2 

Southard,  E.  E.  Cross-sections  of  Mental  Hygiene,  1844,  1869, 
1894.  '  Presidential  Address  at  the  Seventy-fifth  Annual 
Meeting  of  the  American  Medico-Psychological  Association, 
Philadelphia,  June  18  to  20,  1919.  American  Journal  of 
Insanity,  1919,  LXXVI,  91-111. 

Address. 

My  task  was  to  speak  of  an  anniversary.  I  have  adopted  the 
device  of  cross-sectioning  the  years,  no  doubt  at  all  too  brief 
intervals  in  so  long  a  history,  and  beyond  question,  choosing  facts 
in  quite  too  random  a  fashion.  Yet  the  variety  and  the  hetero- 
geneity of  the  facts  and  the  arbitrariness  of  the  trisection  allow, 
with  all  the  greater  certainty,  a  number  of  conclusions  and  com- 
ments. These  I  shall  set  forth  with  a  baldness  quite  unjustifiable 
save  by  the  brevity  of  our  time. 

1.  The  American  Medico-Psychological  Association,  now  over 
900  members  strong  and  representing  a  large  majority  of  the 
United  States  and  the  Canadian  provinces,  being  the  oldest 
national  medical  association  in  continuous  existence  (so  far  as  we 
are  aware)  on  the  continent,  has  a  history  of  seventy-five  years, 
cast  in  a  time  of  almost  unprecedented  interest  in  the  world's 
history  to  date. 

1  Read  in  Charaka  Club,  New  York,  Nov.  19,  1919. 

2  Read  before  Association  for  Study  of  the  Feeble-minded,  Chicago,  June  11,  1919. 


191 

2.  During  these  seventy-five  years  an  extraordinary  process  of 
public  enlightenment  concerning  mental  disease  has  gone  for- 
ward, pari  passu  with  general  progress  in  education  and  the 
more  material  and  engineering  sides  of  economics. 

3.  Put  in  a  phrase,  this  progress  has  been  to  a  deeper  and 
more  pragmatic  hygiene  in  all  matters  pertaining  to  the  mind. 
Perhaps  the  most  eminent  of  our  earlier  members  was  Dr.  Isaac 
Ray,  the  author  of  a  work  on  "Mental  Hygiene,"  in  which  there 
was,  from  our  present  viewpoint,  much  elaboration  of  the  ob- 
vious, and  in  which  there  was  naturally  very  little  of  the  modern 
social  conception.  Yet  Ray  himself  was  one  of  the  founders  of 
the  Social  Science  Association,  and  distinguished  himself,  as  Dr. 
Charles  K.  Mills  this  morning  said,  by  writing  an  excellent  work 
on  the  "Jurisprudence  of  Insanity." 

4.  Just  as  Ray's  "Mental  Hygiene"  was  largely  devoted  to  a 
consideration  of  individual  psychiatry,  and  took  up  the  psy- 
chiatry of  the  person  as  such  and  as  affected  by  various  con- 
ditions of  the  society  in  which  that  person's  life  befell,  so,  on  the 
other  hand,  Ray's  "Jurisprudence  of  Insanity"  dealt  with  what 
we  would  now  call  forensic  psychiatry,  that  is,  with  public  or 
governmental  aspects  of  mental  disease.  Accordingly,  the  whole 
intermediate  realm  of  social  psychiatry  proper,  that  is,  of 
psychiatry  that  deals  neither  with  the  individual  person  as  such 
nor  with  his  legal  or  institutional  relations,  got  no  formulation 
in  the  early  years  of  our  association's  life. 

5.  As  Isaac  Ray  typifies  our  membership  1844-69,  so  perhaps 
Edward  Cowles  typifies  the  membership  in  the  second  quarter- 
century  of  our  association's  existence.  Cowles  stood  —  and 
thank  God  still  stands  —  for  a  profounder  insight  into  the  nature 
and  causes  of  mental  disease  and  defect,  and  no  doubt  to  him  is 
greatly  due  the  impetus  to  the  establishment  of  laboratories  in 
our  institutions.  This  is  no  place  to  eulogize  the  living.  But 
the  third  quarter-century,  now  coming  to  a  close,  could  not  have 
been  so  greatly  distinguished  by  the  laboratories  and  by  the 
exercise  of  what  has  been  called  the  laboratory  habit  of  mind,  had 
it  not  been  for  Cowles.  Nor  is  this  a  personal  view  of  my  own. 
A  dozen  of  the  best  men  amongst  our  psychiatrists  have  said  as 
much  to  me  in  the  last  few  years. 

6.  Perspective  interferes  overmuch  with  our  estimate  of  a 
typical  personality  for  the  third  quarter-century.  I  myself  believe 
that  no  greater  power  to  change  our  minds  about  the  problems 
of  psychiatry  has  been  at  work  in  the  interior  of  the  psychiatric 


192 

profession  in  America  than  the  personality  of  Adolf  Meyer.  If  he 
will  pardon  me  the  phrase,  I  shall  designate  him  as  a  ferment,  an 
enzyme,  a  catalyzer.  I  do  not  know  that  we  could  abide  two 
of  him.  But  in  our  present  status  we  must  be  glad  there  was 
one  of  him.  No  American  theorist  in  psychiatry  of  these  and  the 
immediately  succeeding  decades  but  is  compelled  either  to  agree 
or  else  —  a  thing  of  equal  importance  —  most  powerfully  to 
disagree  with  him.  And  who  shall  say  that  anybody  is  abler  to 
get  truth  and  reality  out  of  disagreement  and  error  than  psy- 
chiatrists? 

7.  The  outstanding  development  in  the  latter  years,  and  espe- 
cially in  the  last  quarter-century  of  the  association's  history,  has 
been,  to  my  mind,  the  development  of  social  psychiatry,  than 
which  it  might  be  hard  to  name  a  more  important  feature  of  the 
face  of  the  world  to-day.  Social  psychiatry,  even  were  we  to 
include  (what  practically  is  not  included,  namely)  public  psy- 
chiatry within  its  conception,  is  far  from  the  whole  of  mental 
hygiene.  For  mental  hygiene  includes  also  the  far  more  difficult 
and  intriguing  topic  of  the  psychiatry  of  the  individual,  as 
related  to  himself  and  his  organs  and  processes. 

8.  Personally  I  hold,  and  I  think  every  physician  and  espe- 
cially every  psychiatrist  must  hold,  that  the  individual  is  not  only 
the  unit  of  the  physician's  interest,  but  also  (following  Herbert 
Spencer)  the  unit  of  the  sociologist's  interest.  This  we  ought  to 
maintain,  I  think,  against  the  supposed  sociological  improvement 
introduced  by  Schaffle,  namely,  that  the  family  is  the  social  unit. 
Accordingly,  I  hold  that  the  foundation  of  social  psychiatry  (as 
also  of  public  psychiatry)  is  the  psychiatry  of  the  individual. 

9.  Now  it  was  just  at  the  outset  of  our  third  quarter-century 
that  Josiah  Royce  made  his  theoretical  contributions  to  the  con- 
ception of  the  social  consciousness  (1894-95).  From  that  at- 
mosphere developed  in  the  work  of  Richard  Cabot  the  idea  of 
medical  social  work.  Mark  you  that  this  idea  was  far  more  than 
a  mere  addition  of  two  ideas,  namely,  the  idea  medicine  and  the 
idea  social  work,  but  was  a  productive  combination  of  these  ideas, 
an  actual  novelty.  It  was  then  only  a  step  to  the  development 
of  psychiatric  social  work  in  Massachusetts,  1912,  a  step  stated 
by  Cabot  himself  (at  the  recent  meeting  of  the  National  Con- 
ference for  Social  Work)  to  be  the  greatest  innovation  in  medical 
social  work  since  its  foundation. 

10.  From  Bakunin  to  Lenin  is  a  half  century.  What  has  the 
world   to   say   of   anarchism   and   Bolshevism?      Certainly   these 


193 

are  no  new  things.  Perhaps  neither  Bakunin  nor  Lenin  is  a 
topic  for  alienists  of  the  old  medicolegal  group.  These  world 
leaders  are  not  on  the  minute  to  be  interned  as  insane!  But  does 
any  man  of  us  here  believe  that  the  psychiatric  viewpoint  could 
fail  to  throw  light  on  Bakunin  and  on  Lenin?  Alone  amongst  the 
specialties  of  medicine,  psychiatry  has  for  its  daily  task  the  con- 
sideration of  the  entire  individual.  The  rest  of  the  branches  of 
medicine,  even  neurology,  appear  to  remain  much  too  analytic  in 
their  view  of  a  man.  Psychiatry  alone  uses  the  daily  logical 
apparatus  of  the  synthesizer. 

11.  Is  mental  hygiene  ready  for  the  problem  of  Bakunin  and 
Lenin?  Alas,  No!  We  have  our  "Varieties  of  Religious  Experi- 
ence," but  no  James  has  arisen  to  depict,  on  the  basis  of  the 
extremest  cases,  the  varieties  of  political  experience.  In  fact,  the 
delineator  of  Lincoln  or  of  Roosevelt  as  in  any  sense  psychopathic 
might  well  bring  down  upon  his  head  far  more  partisan  fury  than 
one  who  should  discover  the  queerest  traits  and  episodes  in 
religious  heroes.  We  deal  with  Aqua  Regia,  with  Damascus 
blades,  in  our  psychiatric  laboratories  and  armories.  "  Divide  to 
conquer"  is  a  necessary  precaution.  We  must  teach  the  world, 
what  we  as  physicians  have  so  recently  learned,  namely,  that  to 
be  crazy  is  to  be  one  of  scores  of  things.  To  describe  Lincoln  as 
a  cyclothymic  with  attacks  of  depression,  or  Roosevelt  as  consti- 
tutionally hyperkinetic  (always  supposing  these  to  be  true  desig- 
nations), should  be  no  more  impolite  or  less  objective  than  to 
think  of  Bakunin  or  Lenin  as  paranoic  personalities.  Crazy? 
No!     But,  cyclothymic  or  paranoic,  certainly! 

12.  Insanity  is  mental  disease,  but  not  all  of  it  or  rather  of 
them.  Alienists  are  psychiatrists,  but  not  all,  or,  in  the  long  run, 
the  majority  of  psychiatrists.  "  Alienistics,"  as  we  may  call  the 
doctrine  of  medicolegal  insanity,  is  not  the  whole  of  psychiatry. 
But,  above  all,  psychiatry  must  be  conceived  to  include  the 
minor  psychoses,  the  smallest  diseases  and  the  minutest  defects 
of  the  mind,  as  well  as  the  frank  psychoses  and  the  obvious 
feeble-mindednesses.  The  psychiatry  of  temperament  is  an  art 
that  might  fling  itself  very  far.  Mr.  Wilson,  I  believe,  spoke 
of  some  members  of  his  cabinet  as  temperamental.  As  a  cat 
may  look  at  a  king  (time  and  weather  permitting),  so  I  suppose 
a  psychiatrist  might  look  at  a  cabinet  officer,  at  least  in  one  of 
his  temperamental  phases. 

13.  WTe  passed  from  the  age  of  Darwin  to  the  age  of  Pasteur, 
to  the  age  of  Metchnikoff  and  of  Ehrlich;    we  lived  through  the 


194 

beginnings  of  systematic  psychiatry  in  the  period  of  Griesinger; 
we  witnessed  the  first  clarifications  of  mental  disease  function  in 
the  period  of  Charcot;  and  we  have  just  concluded  a  war  whose 
psychiatric  achievements  (from  the  deepest  theoretical  side)  trace 
back  to  Charcot,  flowering  to  my  own  mind  in  Babinski.  In 
iVmerica,  outside  institutions,  there  had  been  a  dearth  of  great 
theorists  after  Benjamin  Rush.  But  the  basic  ideas  of  Weir 
Mitchell  were  no  doubt  being  laid  down  in  the  war  time  of  our 
first  quarter-century  only  to  effloresce  in  the  second  period.  The 
work  of  Charles  K.  Mills  stands  out  for  me  as  of  the  greatest 
theoretical  importance  in  American  work  in  that  second  period. 
I  think  of  Donaldson  as  a  great  force  in  our  third  period,  if  we 
are  looking  outside  institutional  ranks. 

14.  But  it  is  clear  that  the  American  idea,  mental  hygiene, 
must  have  grown  in  philosophic  circles  too.  I  think  first  of  the 
great  Emersonian  period,  with  its  grotesque  parody  called  Eddy- 
ism  or  Christian  Science.  Then  I  think  of  the  laying  down  of 
the  idea  of  pragmatism  by  Charles  Peirce,  the  great  and  little 
known  central  figure  of  American  thought.  And  then  I  think  of 
the  man  William  James,  who  put  pragmatism  across  the  Ameri- 
can scene,  but  added  thereto  what  I  may  call  the  'psychiatric 
touch,  and  really  typifies  all  that  is  best  in  American  thought. 
Emerson,  Peirce,  James  —  these  are  three  American  names  to 
conjure  by,  and  they  are  deeply  responsible  for  the  spiritual, 
the  logical  and  the  practical  factors  in  the  whole  of  mental 
hygiene.  With  their  spirit,  illumination  and  dynamism  we  shall 
face  the  terrible  analyses  of  the  present  hour  —  the  rights  and 
interests  of  the  individual  as  against  society,  and  of  society  as 
against  the  individual  —  with  full  confidence  that  synthesis  will 
follow  analysis,  and  the  task  of  Humpty-Dumpty  solved  at  last. 

15.  Do  you  not  agree  with  me  that  in  all  the  pot-pourri  of  the 
years  this  great  problem  of  the  place  of  the  individual  stands 
out?  That  American  thought,  transilluminated  as  always  by  the 
softened  European  lights,  contains  within  itself  immortal  funda- 
ments of  the  mental  hygiene  of  nation,  race  and  person?  And 
may  we  not  rejoice,  as  psychiatrists,  that  we,  if  any,  are  to  be 
equipped  by  education,  training  and  experience  better  than  per- 
haps any  other  men  to  see  through  the  apparent  terrors  of 
anarchism,  of  violence,  of  destructiveness,  of  paranoia,  whether 
these  tendencies  are  shown  in  capitalists  or  in  labor  leaders,  in 
universities  or  in  tenements,  in  Congress  or  under  deserted  cul- 
verts?   It  is  in  one  sense  all  a  matter  of  the  One  and  the  Many. 


195 

Psychiatrists  must  carry  their  analytic  powers,  their  ingrained 
optimism  and  their  tried  strength  of  purpose  into  not  merely  the 
narrow  circles  of  frank  disease,  but,  like  Seguin  of  old,  into  edu- 
cation; like  William  James,  into  the  sphere  of  morals;  like 
Isaac  Ray,  into  jurisprudence;  and  above  all,  into  economics 
and  industry.  I  salute  the  coming  years  as  high  years  for 
psychiatrists ! 


Southard,  E.  E.,  and  Pressey,  S.  L.,  Ph.D.  A  Review  of  In- 
dustrial Accident  Board  Cases  examined  at  the  Psychopathic 
Hospital.  Proceedings,  International  Industrial  Accident 
Boards  and  Commissions,  1917,  Washington,  1919,  159- 
170;  United  States  Bureau  of  Labor  Statistics,  March, 
1919.     No.  248. 

Summary. 

To  sum  up,  then,  I  have  mentioned  a  surprising  number  of 
points  of  contact  made  of  recent  years  by  psychiatry  and  psy- 
chology with  industrial  problems. 

I  have  presented  a  special  report  of  Dr.  S.  L.  Pressey  showing 
the  reliability  of  the  psychological  tests  in  industrial  accident 
cases,  and  Dr.  Pressey  has  included  in  his  report  a  number  of 
special  instances  in  which  the  working  of  these  tests  may  be 
seen. 

A  few  instances  from  our  review  have  been  given,  showing 
the  decided  bearing  which  psychiatric  diagnosis  may  have  upon 
the  findings  for  claimant  or  insurer,  as  the  case  may  be,  and  on 
the  amount  of  compensation  when  rendered. 

A  number  of  pitfalls  of  the  work  have  been  enumerated.  I 
have  laid  the  greatest  stress  upon  psychometric  ("mental  test") 
work  because  of  its  quantitative  nature  and  its  relatively  recent 
developments.  In  the  industrial  accident  board  group,  from  the 
psychiatric  point  of  view,  I  find  cases  of  syphilis  of  the  nervous 
system,  of  feeble-mindedness,  epilepsy,  alcoholism,  focal  brain 
disease,  dementia  prsecox,  and  manic-depressive  psychosis,  to 
say  nothing  of  the  traumatic  variety  of  neuropsychosis  and  the 
number  of  odd  cases  difficult  to  classify. 

I  think  there  is  no  doubt  that  just  as  this  work  will  benefit 
those  physicians  and  psychiatrists  who  are  going  to  deal  with 
the  shell  shock  wrecks  of  this  war,  so  the  entire  work  of  indus- 
trial accident  boards  throughout  the  world  is  going  to  prove  of 
most  concrete  value  in  the  whole  field  of  after-war  re-education. 


196 

Southard,  E.  E.  The  Mental  Hygiene  of  Industry  —  A  Move- 
ment that  Particularly  Concerns  Employment  Managers, 
and  Industrial  Management.  The  Engineering  Foundation, 
Reprint  Series  No.  1,  February,  1920,  LIX,  100-106.  Also 
in  Mental  Hygiene,  1920,  IV,  43-64. 

Summary  and  Conclusions. 

1.  The  general  object  of  this  paper  is  to  set  forth  the  existence 
and  present  rate  of  progress  of  a  movement  for  the  mental 
hygiene  of  industry. 

2.  This  term  mental  hygiene  is  coming  into  general  use  to  cover 
the  expert  activities  of  •psychiatrists  {i.e.,  medical  men  interested 
in  the  problems  of  mental  disease,  including  the  mildest  forms 
of  temperamental  deviation),  •psychologists  {i.e.,  scientific  and 
theoretical  experts,  who  are  now  turning  attention  to  methods 
of  mental  testing  designed  to  improve  and  replace  the  hit-or-miss 
methods  of  the  past),  and  various  non-professional  or  semi- 
professional  aides  (such  as  social  workers  with  special  experience 
in  character-handicap  cases). 

3.  The  recent  improvements  in  employment  management  and 
all  activities  dealing  with  industrial  personnel  show  that  industry 
is  ready  for  the  new  movement,  and  employment  managers 
everywhere  are  displaying  the  keenest  interest  in  the  new  ideas. 

4.  Meanwhile  the  war-time  results  of  the  experts  in  mental 
hygiene  enumerated  in  paragraph  2  have  given  practical  demon- 
stration of  the  value  of  mental  hygiene  in  a  business  partaking 
largely  of  the  nature  of  industry,  namely,  the  business  of  war. 

5.  The  earlier  literature  of  industry  conclusively  shows  that 
the  "mental  hygiene  of  industry"  is  nothing  new  in  its  essence 
(witness,  many  older  references  to  the  human  element,  etc.),  but 
to-day's  contribution  is  the  organization  of  older  interests  for  a 
systematic  attack  on  industrial  personnel  problems. 

6.  The  keynote  of  this  systematic  attack  on  industrial  per- 
sonnel problems  by  means  of  mental  hygienic  data  and  methods 
is  the  pooling  and  co-operative  combination  of  expert  engineering 
interests  and  expert  medical  and  psychological  and  sociological 
interests;  in  brief,  the  invoking  by  the  expert  in  industrial  personnel 
of  the  aid  of  all  available  experts  in  personality,  to  the  study  of 
which  the  whole  personnel  problem  must  reduce. 

7.  The  interested  personnel  man  or  lay  reader  is  implored  not 
to  take  sides  for  one  or  other  claims  or  counterclaims  by  medical 
men,  psychologists  and  others  concerning  the  virtues  of  special 


197 

methods.  The  topic  is  growing  and  a  little  controversial,  but 
on  the  whole,  the  quarrels  about  method  are  superficial  and  the 
unanimity  of  experts  extraordinary  (no  doubt  the  trials  of  the 
war  served  to  mature  and  season  the  experts  on  all  sides). 

8.  Another  warning.  Every  time  the  world  has  tried  to  meas- 
ure things  more  accurately  many  foolish  persons  have  risen  to 
protest.  Not  a  few  medical  men  and  psychologists  will  rise  to 
say  over  the  same  formula  against  the  mental  hygiene  of  industry. 
It  is  to  be  hoped  that,  at  this  late  date  of  the  world's  history,  we 
can  jump  this  zone  of  senseless  protest  against  what  must  in- 
evitably succeed,  namely,  a  program  of  more  expert  study  of 
anything  whatever,  including  the  human  personality,  wherever 
at  work. 

9.  The  movement  for  a  mental  hygiene  of  industry  is  neither 
an  outgrowth  of  the  efficiency  movement  (Taylorism  and  the 
like)  nor  an  outgrowth  of  the  workmen's  welfare  movement 
(economic  interest  in  shorter  hours,  better  working  conditions 
and  the  like),  though  mental  hygiene  does  effectively  combine 
"efficiency"  and  "welfare"  (as  it  were,  F.  W.  Taylor  and  Jane 
Addams). 

10.  On  the  contrary,  a  stream  of  independent  developments  in 
our  knowledge  of  personality  (medical,  psychological,  illustrated, 
for  example,  in  the  kind  of  insight  into  human  nature  displayed 
by  William  James)  is  now  pouring  itself  into  a  branch  of  engineer- 
ing —  personnel  management  —  which  has  been  running  parallel 
for  some  time.  Let  us  think  of  the  movement  in  the  terms,  not  of 
F.  W.  Taylor  nor  of  Jane  Addams,  but  in  terms  of  William  James. 

11.  The  text  contains  sundry  definitions  and  general  statements 
on  these  lines.     Future  papers  will  amplify  the  account. 

12.  Perhaps  the  argument  for  a  mental  hygiene  of  industry 
may  be  put  in  a  nutshell  form  as  a  question:  Why  should  not 
industrial  managers  seek  the  aid  of  (a)  those  who  can  measure 
at  least  a  few  of  our  mental  capacities  and  have  shown  their 
abilities  in  the  war  work;  of  (6)  those  who  are  the  best  special- 
ists we  yet  have  in  temperament  and  the  best  experts  in  griev- 
ances yet  developed;  and  of  (c)  others  less  professionally  trained 
who  are  capable  of  tracing  out  or  helping  to  trace  out  the  actual 
situation  of,  e.g.,  labor  "turn-over"  as  shown  in  the  individual 
instance? 

13.  In  short,  why  not  help  to  push  on  the  movement  for  in- 
dividualism in  industry  that  everyone  sees  coming  and  ardently 
hopes  for? 


198 

Southard,  E.  E.,  and  Solomon,  H.  C.  Morbi  Neurales.  An 
Attempt  to  apply  a  Key  Principle  to  the  Differentiation  of 
the  Major  Groups.  Archives,  Neurology  and  Psychiatry, 
1920,   III,  219-229. 

Summary. 

The  method  of  diagnosis  by  orderly  exclusion,  already  proposed 
for  use  in  the  diagnosis  of  mental  diseases,  is  probably  of  equal 
value  in  the  field  of  nervous  diseases.  The  writers  have  en- 
deavored to  gather  the  main  types  of  nervous  disease  into  a  com- 
paratively small  number  of  groups  for  successive  consideration 
by  the  tyro,  or  even  by  the  expert,  in  diagnostic  elimination. 
Experts  may  prefer  a  different  order  from  the  one  proposed,  but 
it  is  unlikely  that  any  neurologist  fails  to  use,  consciously  or 
unconsciously,  some  form  of  orderly  diagnosis. 

Yet  the  student  is  quite  likely  to  be  taught  that  the  best  pro- 
cedure is  to  pick  out  some  striking  symptom  in  a  case  under  con- 
sideration, and  to  follow  that  symptom  back  to  textbook  models 
for  a  suggestion  as  to  the  entity  involved.  He  then  endeavors 
to  match  the  data  of  the  case  in  hand  with  the  possibilities  laid 
down  in  the  textbook. 

We  think  that  it  is  much  more  desirable  to  take  the  general 
situation  in  the  body  at  large  into  account,  and  to  include,  if 
possible,  first,  the  hypothesis  of  an  infectious  origin  for  the 
symptoms.  Secondly,  we  try  to  exclude,  if  possible,  the  effects 
of  coarse  and  otherwise  destructive  lesions  of  the  nervous  system- 
(historrhexes),  namely,  in  general,  such  conditions  as  show  no 
signs  of  infection,  but  exhibit  reflex  disorders  and  signs  of 
heightened  intracranial  pressure  and  the  like,  suggestive  of  focal 
lesion.  Thirdly,  we  come  to  the  hypothesis  of  the  existence  of 
one  or  other  of  those  classic  degenerations  with  which  the  neu- 
rologist is  familiar.  If  infection,  historrhexis  and  classic  degenera- 
tions can  be  excluded,  we  then  proceed,  fourthly,  to  the  hy- 
pothesis of  some  kind  of  imbalance,  perhaps  metabolic  or  endocrine 
or  sympathetic.  If  the  diagnosis  cannot  be  made  on  these  lines, 
possibly  the  condition  belongs  in  some  miscellaneous  and  other- 
wise undefined  or  highly  specialized  group. 

Even  when  the  disease  seems  to  be  limited  to  a  peripheral 
nerve,  we  consider  that  then  the  successive  hypotheses  of  (1) 
infection,  (2)  historrhexis,  (3)  specialized  neuronatrophy,  (4) 
imbalance,  can  be  preferably  considered  in  that  order.  We  think 
that  by  the  pursuit  of  some  such  method  as  this  the  neurologist 


199 

can  bring  his  work  better  into  line  with  that  of  general  medicine. 
The  method  is,  moreover,  a  very  pragmatic  method,  since  lines  of 
treatment  are  specially  indicated  for  the  different  great  groups 
of  disorders.  But  in  so  difficult  a  field  we  do  not  wish  to  dog- 
matize, and  shall  be  content  if  our  communication  arouses  interest 
in  the  application  of  the  key  or  order  principle  to  the  diagnosis  of 
nervous  diseases. 

Southard,  E.  E.  Trade-Unionism  and  Temperament.  The 
Psychiatric  Point  of  View  in  Industry.  Industrial  Manage- 
ment, April,  1920,  LIX,  265-270.  The  Engineering  Founda- 
tion, Reprint,  Series  No.  2. 

Southard,  E.  E.  The  Modern  Specialist  in  Unrest:  A  Place 
for  the  Psychiatrist  in  Industry.  Journal  of  Industrial 
Hygiene,  1920,  II,  11-19. 


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